1. Introduction

The term case management refers to the assessment process for adults with complex and long term care and support needs.

The Case Management Team provides assessment and support for adults whose health condition requires care and support from professionals, from a number of different agencies. The aim of such specialist provision is to reduce crises, prevent, reduce or delay the onset of further care and support needs, including hospital admission.

An assessment collates information from involved professionals who may include occupational therapists, physiotherapists, community nurses, doctors and speech therapists (see also Assessment chapter).

The assessment will be carried out and coordinated by a social worker who should also liaise with housing, leisure, employment, voluntary sector services as relevant (see Integration, Cooperation and Partnerships chapter).

The adult, and their carer, should be at the centre of the assessment and their views, wishes and aspirations listened to and incorporated into the process.

Case management enables carers and other family members to continue caring for the adult, as long as they are able.

2. Principles of Case Management

The following are the principles which underpin case management practice:

  • ensure the services which are provided are person centred;
  • delivery of service provision in a timely manner, and with an ethos of supporting adults with care and support needs to live safe and independent lives, as far as possible. This includes encouraging positive risk taking (see chapters on Personalisation and Risk Assessment);
  • encourage independence through innovative ways of supporting adults, and their carers, including the use of individual budgets and care and support plans;
  • service delivery using a professionally qualified team with the right skills mix;
  • delegate decision making and financial management to the lowest appropriate level to avoid delay in service provision to the adult and their carer;

3. Responsibilities of the Case Management Team

The team is responsible for a number of different assessments, including:

  • social work assessments: this includes ensuring there are assessments from other professionals from other agencies, which contribute to the complex assessment. These should outline agreed goals and outcomes the adult wishes to achieve whilst at home or in supported living or, where this is not possible in a residential / nursing care placement;
  • Indicative Personal Budget Assessments (see Personal Budgets chapter);
  • assessments carried out under the Mental Capacity Act 2005 (see Mental Capacity chapter);
  • Deprivation of Liberty and best interest assessments (see Deprivation of Liberty Safeguards chapter);
  • carers assessments (see Assessment chapter);
  • financial assessments (see Charging and Financial Assessments chapter);
  • panel assessments;
  • continuing care assessments (see Continuing Care (NHS) chapter);
  • assessment and management of adult safeguarding cases and safeguarding investigations as required (see Safeguarding Adult Procedures);
  • care and support planning: the Case Management Team is responsible for ensuring that services deliver to meet the assessed care and support needs, to enable adults can live safely in their own homes or will organise long term placements into residential or nursing care where no longer possible.

Care and support planning  reviews will be undertaken on a regular basis, in the adult’s home or placement setting (see Care and Support Planning chapter).

4. Case Management Team Criteria

Adults whose care and support needs are within the substantial or critical levels of need (see Eligibility chapter).

The Case Management Team works with adults with complex care and support needs which are ongoing due to advanced age, physical or learning disability, those in receipt of end of life care (see End of Life Care chapter) and those with other long term conditions. These adults are vulnerable and frail, are at high risk of a deterioration in their physical and / or mental health or social situation, and input from a number of different professionals will be needed in order to provide a clear assessment of their care and support needs.

Adults whose care and support needs come within the low or moderate level may be offered advice and information where appropriate (see Information and Advice chapter), or support from the Reablement Service (See Reablement Service chapter).

The Case Management Team also receives referrals for adult safeguarding and for assessment, investigation and management of these cases in line with the local adult safeguarding procedures (see Safeguarding Adult Procedures).

5. Timescales, Outputs and Outcomes

In order to avoid delays to adults and carers receiving assessments and / or services, work within the Case Management Team should be managed in a time and outcome focused manner. Work load management and case load management tools should support this.

Key to the success of time focused casework is regular and high quality supervision, which should ensure staff are supported and caseloads managed safely (see also Supervision chapter).

5.1 Timescales

The following timescales apply:

  • assessments will be completed within two weeks of receipt of referral;
  • care and support provided within 28 days of receipt of referral;

5.2 Outputs

Outputs from the Case Management Team are:

  • social work assessments;
  • Indicative Personal Budget Calculations;
  • multi-disciplinary / multi-agency assessments;
  • mental capacity assessments;
  • Deprivation of Liberty assessments;
  • safeguarding assessments / investigations and reviews;
  • carers assessments;
  • panel assessments;
  • continuing care assessments;
  • financial assessments;
  • referrals on to other services including primary and/or secondary health services, the police, Reablement Service, community support, voluntary sector including religious and cultural services;
  • ensuring care and support (for adults) and support plans (for carers) are in place (see Care and Support Planning chapter).

5.3 Outcomes

Outcomes from the Case Management Team are:

  • timely provision of assessment and care and support services;
  • adults with care and support needs achieving their desired goals with maximum independence;
  • adults with care and support needs living safely in their own homes or other home like settings;
  • reduced numbers of adults with care and support needs entering long term placements;
  • increased numbers of adults with care and support needs in employment.
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