Skip to main content

Case Management

Case Management framework​

In Australia there are guidelines, policies, and standards developed by different government agencies and organisations to guide practitioners in providing coordinated, client-centred support and care across various sectors, such as child protection, health, and family violence.

These frameworks typically include phases like screening, assessment, planning, and evaluation, emphasising multi-agency collaboration, risk assessment, and culturally responsive practices to ensure the safety and well-being of clients within their broader social context.

Case Management​

Case management typically include six core elements:

  • Client identification and eligibility determination
  • Client assessment
  • Care planning and goal setting
  • Plan implementation
  • Plan monitoring
  • Transition and discharge

Client identification and eligibility determination​

Case finding describes a process involving activities focused upon the identification of patients/clients not currently receiving case management services. Establishing rapport consists of building an interpersonal connection between the case manager and the patient/client.

Client assessment​

Assessment refers to construct a detailed, comprehensive understanding of the patient/client which includes, their healthcare and social needs, their capabilities, and the resources they have access to in their family and community.

Care planning and goal setting​

Planning encompasses the steps necessary to build a care plan that defines treatment goals, tasks and actions needed to move towards those goals, access to specific services and supports required to achieve the stated goals and final the identification of targeted outcomes that are specific to that the patient/client. Navigation encompasses the part of the case management process where the case manager helps guide the patient/client to services and supports recognizing and working to remove barriers that can either be anticipated or those that unexpectedly arise. Provision of care occurs when the case manager is also part of the treatment team as might happen in the mental health setting. For example, where the patient' s/client's case manager might also be part of the therapy team providing counseling and skills training.

Plan implementation​

Implementation, is the part of the case management program where the plan of care with its varied activities and tasks, is set in motion. Coordination is related to navigation but is broader and refers to the myriad of facilitations that must occur between and among care providers, service settings, organizations, and institutions with the patient/client also being the focus and at the center of this component of the case management process.

Plan monitoring​

Monitoring occurs throughout the entire process and is related to seeking ongoing feedback and conducting follow-up as necessary to how the plan of care is being implemented and producing results. Evaluation is closely related to monitoring but occurs at specific milestones during the case management process to formally determine if the care plan helps the patient/client achieve progress towards goals and outcomes. Feedback as a component of case management involves communication back to service providers about their services' effectiveness. It supports in assisting the patient/client in making progress as defined in the plan of care. Providing education and information encompasses helping the patient/client and their family/support system develop a deeper understanding of relevant health and health care topics. Advocacy refers to activities directed at empowering the patient/client to pursue services and supports and related accommodations and proper entitlements to their circumstances. Supportive counseling describes the case manager's effort to consistently provide encouragement and emotional support as the care plan unfolds. Administration encompasses the paperwork, report writing, and data gathering and analysis that are part and parcel of the modern health care system.

Transition and discharge​

Transition describes the process when a client is prepared to move across the healthcare continuum, depending on the patient's health and the need for services. The client can be moved home or transferred to another facility for further care. Discharge represents the case management process component in which the patient's/client's case reaches the point of closure, goals are met, and the patient's needs warrant disengagement with the case management process.

Finally, community service development occurs when the case management process uncovers a need or service gap within a given community. Then the case manager catalyzes efforts to create that service or support to fill that gap.

Information Management​

In the Australian human services ecosystem — governed by frameworks such as the Information Security Manual (ISM), Protective Security Policy Framework (PSPF), the ACSC Essential Eight, and specific sector standards like MARAM (Family Violence Multi-Agency Risk Assessment and Management) or the National Standards for Mental Health Services — data collection must strictly balance client-centricity with compliance, privacy, and security.

When designing or operating a case management system within this context, the following information should be systematically captured during each of the six core business processes.

Client identification and eligibility determination​

The focus of this initial entry gate is establishing the identity of the individual, identifying immediate crisis indicators, and verifying statutory or program thresholds while ensuring informed consent.

  • Core Identity Data: Full legal name, preferred name, alias, date of birth, gender identity, and physical address. Unique identifiers such as the Individual Healthcare Identifier (IHI) or specific agency case numbers.
  • Cultural & Diversity Identifiers: Aboriginal and/or Torres Strait Islander status (crucial for culturally safe care pathways under Closing the Gap targets), preferred language, interpreter requirements, and country of birth.
  • Consent & Information Sharing Control: Explicit flags indicating informed consent status, signed release of information (ROI) boundaries, and privacy disclosure acknowledgments.
  • Initial Triage & Eligibility Matrix: Documented criteria met for program entry (e.g., geographic boundary, age bracket, specific income/statutory thresholds).
  • Immediate Safety / Red Flags: Initial safety status indicators (e.g., active domestic violence threat, self-harm indicators, urgent medical requirements).

Client assessment​

This phase forms the baseline clinical or psychosocial record. In Australia, this increasingly relies on holistic, multi-agency risk models (such as the MARAM framework) that assess the individual within their complete social ecosystem.

  • Holistic Biopsychosocial Data: Documentation covering physical and mental health status, housing stability, financial security, and legal/justice involvements.
  • Formal Risk Assessment Diagnostics: Labeled risk ratings (Low/Medium/High) derived from validated instruments, such as the HoNOS (Health of the Nation Outcome Scales) in mental health or child safety risk assessment matrices.
  • Client Strengths & Protective Factors: Personal capabilities, independent coping mechanisms, stable family relationships, and existing community connections.
  • System Interoperability Records: Existing external agency involvement notes (e.g., active NDIS plans, Centrelink status, Child Protection orders, or correctional system mandates).
  • Multi-Agency Consultation Notes: Secondary consultations with cultural advisors, medical specialists, or multidisciplinary panels.

Care planning and goal setting​

This phase translates the assessment into an actionable, transparent roadmap. Under Australian client-centred guidelines, this must be co-designed with the client and clearly track legal/budgetary guardrails.

  • Co-Designed Goals: Specific, Measurable, Achievable, Relevant, and Time-bound (SMART) recovery or support goals authored in collaboration with the client.
  • Actionable Interventions: Clearly delegated responsibilities detailing who (case manager, client, or external service provider) will perform what task.
  • Crisis & Safety Plans: Explicit, step-by-step safety actions, emergency contacts, and safe environments, particularly critical in family violence or acute mental health scenarios.
  • Resource & Funding Allocations: Allocated budgets, approved packages (e.g., My Aged Care packages or NDIS support line items), and brokerage fund approvals.
  • Target Review Schedule: Mandatory milestone check-in intervals and designated review dates.

Plan implementation​

This represents the active coordination and service delivery phase, tracking how resources are mobilized and ensuring external vendor accountability.

  • Referral Tracking Logs: Date, destination, and status of external referrals (e.g., submitted to a community housing provider or specialist clinician) along with formal acceptance notices.
  • Case Notes & Service Touchpoints: Chronological, objective event logs detailing client interactions, phone calls, home visits, and multi-agency case conferences.
  • Brokerage & Expenditure Tracking: Real-time financial ledgers capturing service purchases, voucher distributions, and provider invoices charged against the client's allocated package.
  • Cross-Agency Information Exchanges: Records of secure data sharing executed under legislative provisions (e.g., Child Information Sharing Schemes or Family Violence Information Sharing Schemes).

Plan monitoring​

This phase involves checking the trajectory of the care plan against real-world outcomes and managing systemic variances or unexpected crises.

  • Goal Progress Indicators: Standardized milestone metrics tracking whether goals are Not Started, In Progress, Achieved, or Deferred.
  • Risk Re-Assessments: Re-evaluated risk scores to identify whether vulnerabilities have escalated, stabilized, or decreased over time.
  • Variance & Barrier Logs: Documented reasons for plan deviations (e.g., lack of regional service availability, waitlist delays, or changes in client medical status).
  • Client & Carer Feedback: Qualitative feedback capturing the client’s and their support network's satisfaction with current service delivery and their perceived sense of safety and wellbeing.

Transition and discharge​

The final phase manages the safe exit of the client from the program, ensuring continuity of care and long-term stability.

  • Discharge Reason: Explicit categorization of the closure (e.g., Goals Achieved, Program Expiry, Relocation Out of Area, or Transition to a Higher/Lower Intensity Service Framework).
  • Outcome Evaluation Summary: A comparison comparing baseline entry assessment metrics against exit status data to measure systemic program efficacy.
  • Warm Referral & Handover Records: Standardized handover packets transmitted securely to the receiving agency, accompanied by documented client consent for the transfer.
  • Relapse Prevention & Contingency Plans: Documented self-management strategies and community contact points provided directly to the client to support long-term independence.
  • Statutory & Data Retention Metadata: System metadata defining the mandatory archive duration (e.g., specific state records acts requiring retention periods such as 7 years for adults or until a child turns 25 in child protection contexts) and disposal schedules.

References​

Case Management​