Case Management Guidebook

Comprehensive guidance and support to professionals working in homeless and drug services

Executive Summary

The Case Management Interagency Protocols have been developed to guide the working processes of frontline workers in homeless and drug services1. The purpose of the protocols is to:

  • Clarify the way in which multiple agencies can work together to assist service users in achieving their personal goals.
  • Ensure that service users do not fall through ‘gaps’ in services provision.
  • Reduce duplication of services.
  • Improve outcomes for individuals with high or diverse support needs.

The protocols consist of nine guidelines for practi-tioners working in case management. These are:

  1. Holistic Needs Assessment/establishing lead agency
  2. Referral
  3. Interagency case meetings
  4. Confidentiality and data protection
  5. Gaps and blocks
  6. Grievance procedure for service users
  7. Grievance procedure for service providers
  8. Service user disengagement
  9. Positive case closure

The main elements of the case management process are captured within these protocols, and the main steps to be followed are as follows:

A Identify a lead agency and case manager (see Protocol 1)

B Complete a detailed assessment and support plan (see Protocol 1)

C Coordinate interagency involvement in support plan goals (see Protocols 1, 2, 3, 4)

D Deal with difficulties in interagency coordination (see Protocols 3, 5, 6, 7, 8)

E Ensure a continuum of care for the service user (see Protocols 1, 2, 3, 8, 9)

F Respond to service user disengagement appropriately (see Protocol 8)

G Ensure case closure is clear, agreed and appropri-ately planned (see Protocols 8, 9)

These steps in the case management process are described in more detail below (also see Figure 4. for a diagrammatical overview of those steps):

A) Identify a lead agency and case manager

During the first contact with the service user in relation to case management, the worker should ensure that the service user has a good understanding of what case management entails and what steps are involved. When a service user agrees to be case managed, the worker should then check whether a Holistic Needs Assessment (HNA)2 has previously been completed and also check that a case manager is not already attached to the case. They should do this through dialogue with the service user, by checking the LINK system3, and, where appropriate, contacting relevant services which are engaged with the individual. It may be necessary to meet with other agencies to agree who is best placed to manage the case.

B) Complete a detailed assessment and support plan

For homeless services this will be the Holistic Needs Assessment and support plan4. Before carrying out the assessment, the case manager should seek the agreement of the service user for the assessment process to take place and also consent to have the case manager share information about them with other relevant services/agencies; securing this agreement ensures that the service user has a good understanding of what is involved. The outcome of the assessment process is a completed Holistic Needs Assessment and support plan which identifies the service user’s goals, options for service delivery, steps involved in achieving goals, and next steps for involving other agencies in the support plan.

C) Coordinate interagency involvement in support plan goals

There a number of steps to be taken in order to coordinate involvement in the support plan:

  1. The case manager needs to confirm other service’s involvement in the support plan by letter/email/ phone. The service user needs to provide consent for this as part of the assessment process.
  2. Where there is some coordination of the plan required, the case manager should meet the relevant key worker/s (or contact them by phone) to discuss the sharing of responsibilities, agreed targets and timelines. This should be recorded on the support plan and sent to all services involved.
  3. There are some basic actions to be progressed in the very early stages of the process (in discussion with the service user). These are:
  • Ensure that the service user is registered with the local authority on the social housing waiting list, and also registered as ‘homeless priority’.
  • Apply for a medical card.
  • Ensure that they are registered with a GP and have access to the GP as necessary.
  • Ensure that they are registered with a drug treatment service if needed.
  1. The next task is to involve new services so as to ensure that all of the service user’s needs will be met. This will be done through existing referral procedures, and may involve a case meeting where the plan cannot be agreed by phone and mail correspondence.
  2. Case meetings will be held to progress the devel-opment of the plan in the following situations:
  • A lead agency/case manager cannot be agreed.
  • Unmet needs cannot be matched to services.
  • Lack of clarity or different understandings of the case between services.
  • It is the most time-efficient process available due to the number of services involved.
  • Exclusion from lead agency, requiring immediate effect.

D) Deal with difficulties in interagency coordination

Differences in the views of professionals around the service user’s support plan can be considered a strength when managed effectively, as each agency can bring a different perspective and information to the process. The protocols outline how interagency case meetings should be organised and managed and when these should be held. They also outline grievance procedures for service users and service providers. If issues cannot be resolved through these processes, a Gaps and Blocks Reporting System is in place for homeless services through the Quarterly Service

Activity Report5 . Case managers should advise line managers of gaps and blocks to be reported as they arise. All gaps and blocks reported to the Homeless Agency6 will be followed up in the following ways:

  • The service provider will be supported to seek a practical resolution to the issue through interagency mediation or by acquiring additional information.
  • If the issue is due to macro-policy issues or if no service currently exists to meet this gap, then the information will be forwarded to the ‘Pathway to Home’ Implementation Advisory Group and Board of the Homeless Agency, in order to seek policy/ practice solutions to the issue.

E) Ensure a continuum of care for the service user

The service user should remain supported within the case management system until the case is closed. Services providing case management need to agree to undertake the role for a minimum period of six months for each case. An exception to this is when a positive onward referral has been identified within the six-month period and another service can take up the role of case manager as part of this progression. The aim is that the service user will be case managed until support plan needs have been addressed.

F) Respond to service user disengagement appropriately

If the service user is disengaging from services offered, generally this means that they are not attending, or do not want the case manager to communicate with any other services. In this case, a number of steps can be pursued. If unsuccessful with Step 1, the case manager should proceed to Step 2 and so on:

  1. The service user should be offered another case manager service if possible.
  2. The service user needs to be offered key working, with a view to moving back into case management at some time in the future.
  3. If another service is better placed to provide key working, the case should be transferred to a different key working service.
  4. Clarify the minimum level of engagement required in order for the service user to remain in the service and maintain contact, even if key working has not taken place.
  5. If a continued service is not possible and there are concerns for the service user’s welfare, the last option is to formally hand over to a ‘no-threshold tracking’ service. Dublin Simon Rough Sleeper Team and Focus Ireland Outreach Team will provide this service which involves tracking and monitoring the service user’s whereabouts and ensuring that they are aware that the offer of case management is available. The tracking service will inform the case manager of the service user’s response to this offer.

G) Ensure that case closure is clear, agreed and appropriately planned

In order for a case to close, and for the case management relationship to cease, it must be clearly agreed with the service user that all support plan needs have been met and that the individual no longer requires this level of support. An aftercare plan is then agreed with the service user. This plan highlights the steps to be taken if supports are required for any reason in the future. In all cases, the plan requires sign-off from a line manager.

1The Board of the Homeless Agency adopted the protocols as the standard operational procedures for case managers working in the homeless services in November 2009. In relation to drug services the protocols were established and trialled with the NICDTF and SICDTF areas. These protocols have not been agreed by all drug services within Dublin. The evaluation of the pilot of these protocols will be fed into the National Drugs Rehabilitation Implementation Committee to contribute to future policy making concerning case management within the sector.

2 The Holistic Needs Assessment is the standardised assessment and support planning tool which has been adopted across homeless services.

3 For Homeless Services see Case Management Guidebook Accommodation Chapter for details on the LINK system.

4 For drug services the National Drug Rehabilitation Implementation Committee are currently agreeing national standards for the development of assessments and case management systems. The final evaluation of the interagency Case Management Protocols Pilot will assist in informing this process.

5 These Quarterly Service Activity Reports are completed by line management in services, and returned to the Homeless Agency.

6 A comparable system for drug services is currently not in place.