Case Management Guidebook

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


i Overview

Case management aims to support and develop the self-care capacity of the person with high and/or diverse support needs. These protocols have been developed as part of a case management pilot led by the Homeless Agency Partnership and the Progression Routes Initiative.

The protocols outline how numerous services can coordinate effectively to help service users achieve their support plan goals. They describe working processes for case managers, and provide instruction on how to improve service users’ access to, and progression through, services.

ii Development of the Case Management Interagency Protocols

The protocols were adopted as the standard opera-tional procedures for case management in Homeless services by the Board of the Homeless Agency in November 2009. The protocols have been developed in accordance with:

  • Core Action 4 of the Homeless Agency Action Plan 2007-2010, A Key to the Door
  • Pathway to Home Implementation Plan for homeless services
  • National Drug Strategy
  • Report of the Working Group on Drugs Rehabilitation 2007; Key Recommendation 1.

The Homeless Agency Partnership is comprised of a range of statutory and voluntary organisations working together to implement ‘A Key to the Door 2007-2010’ (the agreed action plan on homelessness in Dublin), and to realise the vision of eliminating long-term homelessness and the need for people to sleep rough by 2010.

The Progression Routes Initiative was established in 2006 to develop responses to identified service barriers in relation to the continuum of care for drug users. The project is funded through the North Inner City Local Drugs Task Force on behalf of the HSE.

In 2007, a project partnership was formed between the Homeless Agency Partnership and the Progression Routes Initiative to develop and then pilot case management interagency working protocols. The partnership was based on the potential interrelatedness of homelessness and drug use in service users’ lives and was aimed at enhancing intersectoral as well as interagency working in order to better respond to service users with diverse or intensive support needs.

An Interagency Protocols Working Group (IPWG)7 was established, and met several times between July and Sept 2007. The role of this group was to inform and guide the development of clear interagency protocols. The early development of the protocols was also usefully informed by the EQUAL Initiative, which had developed a number of interagency protocols within the Blanchardstown area over the previous two years.

 iii Aims of the Interagency Protocols

The protocols aim to ensure that service users receive the best possible service, which is person-centred, empowering, and promotes progression.

The implementation of the protocols will work towards ensuring best practice in engaging with service users by:

  • Ensuring that all service users have an assessment, a support plan (which identifies service user needs and priorities), and a dedicated case manager/key worker to drive their support plan.
  • Coordinating services around the service user’s support plan in a clear and consistent manner.
  • Ensuring that blocks to service user’s progression are responded to by appropriate agencies.
  • Ensuring that service gaps are recorded, and reported to the appropriate forum, through the gaps and blocks protocols.

 iv Establishment of a Pilot Steering Group

A pilot steering group was established to monitor and guide the roll out of the pilot and final evaluation, as well as to assist in responding to service barriers as experienced throughout the pilot.

v Interagency Protocols Pilot

Following the finalisation of the draft protocols, a pilot period was planned. This pilot aimed at improving the protocols, based on learning from their implemen-tation in practice. Specifically, the pilot set out to:

  • Support the development, refinement and management of standardised care and case management interagency protocols in preparation for mainstream implementation in drugs and homeless services.
  • Oversee the initial practical application of the Care and Case Management Interagency Protocols Pilot in both homeless and drug services for a period of one year.
  • Support pilot sites in the provision of effective care and case management to service users; supporting individuals through a continuum of care.
  • Undertake an ongoing process review and final evaluation, focusing on case progress and the experience of case managers.

The pilot had two phases, the first beginning in June 2008 and the second in January 2009. By the time the pilot ended (June 2009) it had involved 111 cases and 59 case managers.

The pilot comprised a number of elements including:

Selection of case managers and cases

An open invitation was issued to homeless and drug8 services to nominate case managers for involvement in the pilot. Efforts were made to select a broad range of services for inclusion. These nominations were then agreed through the Care and Case Management Steering Group of the Homeless Agency, the Progression Routes Advisory Group and the Pilot Steering Group.

Individual cases to be case managed were nominated by services. Guidance was provided that cases needed to have a degree of complexity in that there was a range or severity of needs experienced by the case, or that there was some level of difficulty in coordinating services to respond to those needs. Cases were also required to be currently homeless or very recently homeless.

For Phase One, all cases were single adults. For Phase Two, this was broadened to include families, as well as young adults aged 18-25 years.

An information sheet was prepared for the service user. Case managers approached service users directly to request their involvement in the pilot.

It should be noted that service user information was anonymised in both the reviewing and monitoring aspects of the pilot, and this limited the factors which needed to be considered by service users when deciding whether they would agree to participate.

Case manager and line manager training and briefings

The pilot involved:

  • One-day training session for all case managers in the use of a common assessment tool: the Holistic Needs Assessment. This tool had previously been developed by the Homeless Agency.
  • An orientation day for case managers on the use of the protocols, including how to establish the lead agency and broker services’ involvement in the care plan.
  • Three training/briefing sessions on the protocols for all line managers and implementation advisors.

Third level accredited case management module

All case managers undertook a six-day, accredited case management professional development module, which was developed with Dublin City University and was entitled ‘Case Management and Collaborative Working with People with Complex Needs (Homeless and Drug-using Clients)’. This course stands at level eight in the National Qualifications framework.

The topics covered in this module include among others: the theory of case management, interagency negotiation, managing case meetings, dealing with challenging behaviours, reflective practice, policy and ethics.

Process review

Multiple feedback mechanisms were developed to ensure that the protocols and pilot process could be adapted to reflect the experience and guidance of the case managers involved in implementing the protocols. Feedback mechanisms included:

  • Regular meetings between the pilot coordinators and the implementation advisors who were the senior line managers responsible for the roll out of the pilot within a particular service.
  • Regular opportunities throughout the training/ briefings for feedback and evaluation of all aspects of the pilot.
  • review forms were completed every two months by case managers. A case review form was received in relation to every case involved in the pilot; this included information on severity of service user needs and service access for each area of the support plan. A case manager review form was also completed every two months. This gave case managers an opportunity to comment on their workload, and the supports provided to assist them in their role. It also gave them an opportunity to comment on whether the protocols were useful or whether they required any amendments.
  • part of the process review, two new protocols – the disengagement protocol and the positive case closure protocol – were added during Phase Two. The case manager feedback was also extremely useful in providing clarity on small changes and additions to the protocols and supporting documentation.

vi Final Pilot Evaluation

A final evaluation was undertaken following completion of the pilot in June/July 2009. This evaluation was based on the following:

  • Information on 111 cases provided through the case reviews sent in every two months by case managers.
  • Case manager reviews: information from 59 case managers involved in the pilot regarding the protocols and the pilot structure. These were also sent in every two months by case managers.
  • Surveys from the implementation advisors/line managers, which were completed at the end of the pilot.
  • In-depth interviews with eight service users, which were selected to represent the range of outcomes including disengagements, no progress, some progress, and very positive progress.
  • Surveys with the key working agencies involved in the cases, as above.

The Evaluaton Report is available on www.homeless and

vii Who are the protocols for?

These protocols have been developed for use by case managers and line managers in homeless services in the Dublin region, and for use in drug services in the North and South Inner City Local Drug Task Force areas.

It should be noted that not all services detailed in the comprehensive listings section, (over 450 from the social care spectrum), have been involved in devel-oping the protocols or have formally agreed to work in the ways outlined by them.

The protocols will be useful for any services interested in detailed information about the case management approach being used by homeless services and some drug services; who were engaged in the pilot.

The protocols may also be useful for key workers who are in communication with a case manager and wish to know more about the model guiding this work.

 viii Definitions


It is acknowledged that throughout services different terms are used including; service user, client, customer and patient. It has been agreed that the term ‘service user’ will be primarily used in this documentation to describe any person availing of or requiring a service and whom therefore requires a case manager/key worker to assist them in achieving their support plan goals.


This is the questionnaire used to gather information from service users in order to work out what their needs are and in what priority these should be addressed in the support plan. The assessment tool is not a diagnostic tool and it is not intended to replace other specific professional assessments; rather it is designed to work in conjunction with these, and to flag which professional assessments are required. The Homeless Agency’s Holistic Needs Assessment is the common assessment tool used by homeless services.


The support plan is a course of actions agreed between the service user and service(s) that outline the service user’s goals and how these will be met. The support plan is developed on the basis of findings during the assessment process. It sets out timelines for the completion of goals and identifies clear areas of responsibility. The support plan is referred to as a ’care plan’ within some services.


Please see above section on support plan. This is referred to as a support plan throughout this documentation.


Intensive engagement with a service user who has a broad range of needs or intensive support needs, in order to ensure that multiple services are effectively coordinated to respond to those needs. This role has responsibility for brokering as well as coordinating services to meet all support needs.


The process of taking into account all factors relating to the service user’s wellbeing.


This role involves working with the service user to achieve the goals in the support plan, as they relate to the work of the key working service.


The lead key worker who coordinates services involved in the support plan and holds/has responsi-bility for the assessment and support plan. This worker undertakes support plan reviews and generally has the most contact with the service user.


This is the agency which has one or more of the following: 1) the most contact with the service user or client, 2) a statutory obligation towards the service user or, 3) is best placed to meet the core needs in a service user’s support plan. The case manager will be housed within the lead agency.


This role focuses on structures and policies to support effective case management, in particular any blocks and barriers that the case manager experiences.


This role involves supervising the case manager and providing managerial support should there be questions around process and outcomes.


During the pilot project this role involved senior service/agency managers with responsibility for overseeing the protocols implementation in their service and/or responding to barriers and developing services in response to these.


Senior service/agency representatives with responsibility for overseeing and guiding the pilot.


Children First Guidelines state that every service should have a nominated child protection officer (CPO). It is the responsibility of this person to be familiar with child protection reporting requirements and to inform other staff of their legal responsibilities in communicating any relevant issues to the CPO/HSE. All agencies should have a child protection policy and procedures in place.


This is a mechanism by which case managers and their line managers/implementation advisors inform policy forums of the systemic issues that impede a services user’s journey through services. For homeless services this happens through the Quarterly Service Activity Reports completed by the management in a homeless service and returned to the Homeless Agency every three months.

 ix Outline of Roles - key worker and case manager

When a service user has a diverse range of needs, or very high support needs it is unlikely that one service will be able to meet all of these needs. In such cases, a number of key workers from different services will be required to engage with the service user to address the variety of issues involved. In order to improve communication and clarity, the services should jointly agree that one lead key worker will manage the inter-agency communications and ensure that all services are fulfilling their part of the care plan. Ideally, this worker will be the case manager.

The case manager role can be adopted by a project worker/key worker for certain cases by elevating the intensity of the engagement with the service user and coordinating interagency involvement in the support planning process.

The case manager’s role involves working with both the service user and all other key workers. Therefore, case management requires more time input per service user than key working alone. The differences between the roles of case manager and key worker are defined below:

key worker

Guideline time commitment is one to two hours per week. Tasks include:

  • Engaging with service user.
  • Ensuring consent.
  • Completing assessment and support plan.
  • Advocating on behalf of service user.
  • Working to fulfil support plan actions relating to their service goals.
  • Keeping relevant case notes/records.

Not all service users will require time-intensive case management. Set out below is an overview of situa-tions where a dedicated key worker may be sufficient to meet service user needs, and case management is therefore not required.

Case manager

Guideline time commitment is two to three hours per week for an individual and three to four hours for a family.

As outlined previously, the case manager does the same work as key workers, but also liaises with other key workers to coordinate a multi-agency support plan, specifically:

  • Drawing together a case management team comprising all relevant key workers.
  • Facilitating this case management team to develop and agree a support plan either by phone/email, or through a case management meeting.
  • Acting as the contact point for the case management team and the service user.
  • Overseeing implementation of support plan.
  • Maintaining the full case file i.e. assessment, support plan, and updates/agency reports.
  • Communicating any relevant gaps/blocks/barriers to the appropriate forum through their line management.
  • Remaining as case manager until the case is formally handed over to a new case manager or until disengagement or case closure processes are followed.

It is important that services make adequate provision for staff cover for both holidays and shift work situations.

 x Model underpinning the Interagency Protocols

The lack of effective interagency communication and collaboration is highlighted in Figure 1. Many key workers may be involved with a service user, but without an identified lead key worker, communication is likely to be sporadic and uncoordinated.

The example outlined in Figure 3. is only one of many possibilities of a transfer, which could equally move from a housing service to a drug service. It highlights the fact that once the HNA and support plan have been formally handed over, there is a possibility that the previous case manager will remain engaged with the service user as a key worker.

Housing services are moving towards a model whereby there will be fewer transfers between homeless services and housing services, with the case manager staying with a case until support plan goals have been achieved.

Within drug services, there may be a number of transfers as a service user moves from low-threshold services through to stabilisation, rehabilitation and aftercare services.

When transferring between services, the important factors are clarity on role, continuity of the support plan and an assurance of care into the future.

Common to all services is the requirement for a commitment from the case managing service to maintain this role for a minimum of six months. The only exception to this is if a positive onwards referral is identified i.e. where the new case manager is better able to meet the service user’s needs and is able to commit to case managing for a minimum period of six months. The important factor in any continuum of care is that once a service user has a case manager they will continue to receive this support until they no longer require it.

If the service user wishes to disengage from the case management process, they will be offered another case manager or will be given the opportunity to return to key working services, which require a lesser level of commitment. It is important that the option of having a case manager is kept open to individuals at all times. The disengagement protocol details how this should happen.

7 Membership of this IPWG included: Sam Priestley, DePaul Trust; Ronan O’Connor, HPU; Carmel Brien, Gateway; Sonya Dillon & Gerry McAleenan, SOILSE; Ger Kane, HSE Social Inclusion; Orla Ryan ; Joan Byrne & Siobhan Cafferty, SAOL; Mark Graham, Access Team; Orla Grimes, South Dublin City Council; Paul Kelly & Elaine Fleming, Focus Ireland; Julian Pugh, HSE Prison Services; Mary Hayes, DCC; Jason Watson, HSE Child Protection; Ruaidhri McAuliffe, UISCE; Sean Dunne & Bernie Cummingford, NWT&DP; Dermot Murphy, Ana Liffey; Clare Williams, Peter McVerry Trust; Diarmuid Breathnach, De Paul Trust/ HSE RIS, Siobhan Collins; Marie Connors, SNUG; Gerry Rafferty, BRIDGE; Elaine Butler, Homeless Agency; Caroline Gardner, Progression Routes.

8 As noted in Phase 1 this included drug services associated with the North Inner City Drugs ask Force, In Phase two this was extended to include services from the South Inner City Drugs Task Force.

9 Care Manager: During the Intragency Protocols Pilot, this role was undertaken by the Homeless Agency Partnership and the Progression Routes Inititiative.