Case Management Guidebook

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

Holistic assessment/establishing lead agency

Once a service user contacts your service with a range of intensive support needs and a desire to address these needs, the following steps should be taken to progress the case:

  1. Identify lead agency/case manager.
  2. Complete assessment and support plan.
  3. Coordinate service involvement in support plan where required.
  4. Monitor support needs and outcomes.

Step 1: identify lead agency and case manager

The lead agency will take responsibility for holding and managing the overall support plan. Within the lead agency a designated worker will be assigned to the service user who acts as the case manager or key worker, as appropriate.

The worker should establish whether the service user has existing key workers/case managers in any other services, and whether any of these are acting in the role of case manager. After seeking the service user’s permission, the case manager should:

  1. Ask the service user whether they have completed an Holistic Needs Assessment (or for drug services another form of assessment) and whether they have a case manager or key worker involved. The case manager should list the services they are working with, and the relevant contacts within each service.
  2. In the case of homeless services, check the LINK system. In the case of drug services, contact will need to be made with involved services by phone or letter.
  3. As necessary, phone services to enquire about whether they are in the role of case manager; whether the Holistic Needs Assessment has been completed, and whether they will be able to play a part in the support plan in the future. This may be useful if the services that the service user is engaged with are not involved in the LINK system10.

IF THE SERVICE USER DOES NOT HAVE AN AGENCY WORKING WITH THEM ALREADY, they should make an informed choice, with information provided by the worker as to the best service to act as their lead agency and case manager. The service, which is the first point of contact, should explain how the protocols work, namely that there should be one lead agency which can best address their needs at the time. The individual should be informed that this role might change as they progress through services, or as their needs change, although they will continue to be provided with a service until they no longer need it.

The worker should also explain that the case manager will be in contact with other services to make sure that they are fulfilling their duties as outlined in the support plan. The Service user Information Sheet (Appendix A) may be given or read to the service user so as to ensure that they are aware of what case management means for them.

IF AN ASSESSMENT HAS ALREADY BEEN COMPLETED with the service user’s permission, the worker should make contact with the identified case manager. Potential involvement in the service user’s support plan should be discussed with the service user and agreed with the case manager.

IF TWO OR MORE SERVICE PROVIDERS REGARD THEMSELVES AS BEST PLACED TO BE THE LEAD AGENCY, the service user’s choice should be facili-tated, as should an interagency discussion regarding which service is best placed to meet the support plan goals. The case manager will, in most circumstances, be located in the agency which has the most interaction with the service user, or which has responsibility for the most support plan actions.

In the unlikely event that agreement cannot be reached, the service user will make the final decision, except in cases where one agency has a statutory obligation to the service user. Examples of such exceptions would include cases such as:

  • The service user is under 18 years.
  • The service user is a sex offender/is under a statutory supervision order.
  • The service user has a disability, which necessi-tates the HSE having responsibility for that individual’s welfare.
  • Where child protection issues11 are involved, the social worker has statutory responsibility for the case, and a distinction will be made between the case manager for the individual, and the social worker who is the case manager for the child and the family in the context of a child protection case.

The role of the case manager will be to support the work of the social worker through involvement in a care plan relating to the family. Social workers have statutory responsibility for calling ‘case conferences’ relating to child protection issues. Case conferences have specific roles and statutory requirements and should be viewed as distinct from case meetings, which are not statutorily binding. If you are acting as case manager you should inform the social worker of this so that you can be invited to case conferences and ensure that there is a clear understanding of roles and responsibilities.

Case managers are able to call ‘case meetings’ in relation to care plan issues; case managers should involve a social worker in such meetings in circum-stances where a social worker is assigned to the child and family, and where this role relates to the immediate care plan issues.

IF SERVICE PROVIDERS ARE NOT SATISFIED WITH THE SERVICE PROVISION of other agencies or with the outcomes of the interagency process, they should try to resolve this at a management level between services. If this is not successful, then they should refer to the service providers grievance procedures outlined in this document (see Protocol 2.7).

Step 2: Complete assessment and support plan

If an Holistic Needs Assessment has not been completed, the case manager within the lead agency should complete, or ensure completion of, both the assessment and the support plan.

Step 3: Coordinate service involvement in the support plan

If at all possible, service users should identify and access services for themselves. If this is not possible, the case manager will act as advocate on the service user’s behalf. Advocacy will, ideally, be a temporary measure until such time as service users can access services independently12.

In general, the support plan will be agreed by phone and mail communication or through a case meeting. Both processes are described in the next paragraph:


Coordination of services by the case manager should first be attempted by phone and mail communication. If a support plan can be agreed in this way, then there may be no need for a full case meeting. However, if a case meeting is feasible and if it will benefit future working relationships between the service user and services, then this option should be progressed.

If the support plan can be established without the need for a case meeting, then a letter confirming involvement in the support plan needs to be sent to all services involved in the case. In some cases, service provision will not change as a result of the involvement of the case manager. In such instances, it is still paramount that all services are aware of the case management role. Where there is a longstanding relationship between services, this communication may take place in person rather than through a formal letter. In all cases, records of communications will need to be kept. The important outcome is that all services are informed of:

  • The name and contact details of the case manager.
  • The fact that there is an interagency support plan in place and that the service has agreed to share information between services.
  • Their own role within the support plan and any details of what service is to be provided and by what timeline.
  • Who to contact should any issues arise

A template of the case manager’s introduction letter is set out in Appendix D. As well as ensuring that services have the case manager’s contact details, the letter offers to provide further information on the support plan or the case meeting should this be requested by the key working service.

In cases where the service user is engaged in a methadone maintenance programme, the letter should be sent to the prescribing doctor13. In all other cases, it should be sent to the key worker or other named contact person within the service. If a contact person cannot be named by the service user then the case manager should phone the service to ascertain the relevant contact person’s details before any corre-spondence is dispatched.

In instances where the letter is the first introduction to the case manager, this should be accompanied by a copy of the signed confidentiality form.

In all cases, and as part of the support plan process, the service user should be aware of the role that each agency plays in the support plan. They should also be aware that each agency will be contacted by the case manager.


As stated, if the support plan can be agreed and progressed outside of a case meeting, then this will make the most efficient use of resources.

However, a case meeting will definitely need to be called when one or more of the following situations occur:

  • A lead agency/case manager cannot be agreed.
  • There are a number of unmet support needs and there is no plan as to how to address these needs despite having made reasonable efforts in one-to-one communications with service providers.
  • Services have different understandings of the case or there is lack of clarity as to involvement in the support plan.
  • The case involves several agencies and it is more time efficient and effective to discuss the support plan at a meeting rather than in a one-to-one contact situation.
  • The service user is excluded from the case manager’s service, and the role of case manager needs to be transferred.

In any of the above five instances, problems in convening case meetings are to be recorded and reported to the line manager in the service. For homeless services this would be through the gaps and Bocks Reporting Form, which comprises part of the Quarterly Service Activity reports to the Homeless Agency. (A copy of the gaps and Blocks Form can be found in Appendix I).

case meetings are to be run as described in these protocols. All outcomes should be noted in the support plan, which will form the basis of the minutes of the case meeting and will be distributed to all involved, as required.

Figure 4 describes the protocols in practice.

Step 4: Monitor support needs and outcomes

The completed assessment and support plan should prompt effective monitoring of the service users support needs and outcomes. The following should be regularly reported to the line manager of your service:

  • Levels of support needs for all assessments and domains.
  • Progress/achievements of support plan goals.
  • Referral.
  • Blocks/ gaps to support plan goals.
  • Positive case closure.
  • Disengagement.

10 It should be noted that currently there is a trial within the HSE Northern area of an information system (DAIS), which has a capacity to record case management functions. The long-term goal is that the HSE will have a system that records the case manager role and basic care plan information to support interagency working practice, as described in the Report on Drugs Rehabilitation, May 2007.

11 No part of this protocol can limit or interfere in any way with the statutory function of the HSE to protect children. Services signing up to the protocols need to undertake to engage effectively with Social Work around issues of Child Protection as outlined in the Children First Guidelines. It should also be noted that where the case management role is not able to be filled and where there is Social Work involvement it is not to be assumed that the Social Worker will be able to play the role of case manager to the adult involved.

12 Based on the Blanchardstown Equal Initiative: Protocol Pack, page 7, 2004

13 Where the support plan will involve a future referral relating to drug treat-ment, such as to a detox or rehabilitation services and there is a methadone prescribing clinic involved, the support plan should be discussed with the rele-vant person within the clinic before this becomes a formal aspect of the sup-port plan. In a number of cases formal support from the prescribing doctor is required for transfer of medication. A request for this discussion can be includ-ed in the introductory letter.