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CASE MANAGEMENTSERVICE -

A GUIDE FOR SERVICE PROVIDERS

Serial No: 026/SDD15/NOV04

About This Guide

This guide provides an overview and introduction to the mission and

philosophy, goals and objectives, practice functions, and key components of case

management service, and aims to promote effective service delivery to diverse

target populations in Singapore. It is targeted at all agencies that might be

interested in developing community case management services, regardless of

whether they already run structured services for their specific clientele groups, or

do not currently have any concrete programme.

Acknowledgements

We wish to acknowledge Methodist Welfare Services for their valuable

inputs to the development of this guide.

© National Council of Social Service 2004

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National Council of Social Service. All rights reserved. No part of this manual may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without written permission from the National Council of Social Service.

© National Council of Social Service 2004

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Contents

1. Introduction to Case Management Service 1

i. Mission and Philosophy

ii. Brief overview

2. Goals and Objectives 2

3. Target Populations for Case Management Service 3

i. Multi-stressed Families

ii. Post Suicide and Crisis Cases

iii. Family Violence Cases

iv. Youth-at-risk

v. People with Disabilities

vi. People with HIV/AIDS

vii. Elderly with Multiple Needs

viii. Reformed Offenders

4. Practice Functions of Case Management Service 7

i. Assessment

ii. Planning

iii. Intervention

iv. Monitoring

v. Evaluation

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5. Key Components of Case Management Service 11

i. Models of Case Management

ii. Professional Competency

iii. Networking with other Agencies

iv. Programme Evaluation

6. References & Useful Links 14

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1. Introduction to Case Management Service

Mission and Philosophy

The mission of case management service in Singapore is to enhance the

quality of life of diverse target populations residing in the community by

providing on-going support and promoting integration and coordination of social

services. Case management serves as a means for achieving client wellness,

independence and autonomy consistent with the individuals’ capacities through

assessment of clients’ needs, identification of appropriate services, development

of individualised comprehensive plans, advocacy for clients’ access to identified

services, and monitoring and evaluation of the effective delivery of these services.

Brief Overview

What is Case Management?

Case management is a client-centred service that respects the individual’s

dignity, rights, values, and preferences. The case manager works closely with the

client (and/or significant others) in achieving client goals; through needs

identification and individualised care planning and implementation. The case

manager integrates a range of services offered by different agencies in a timely

and coordinated way to address client’s goals and needs as stipulated in the care

plan. With case management, the client is involved in a comprehensive system of

care that is appropriately meeting his or her needs at any point in time as well as

over time.

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2. Goals and Objectives

The goals and objectives of the Case Management Service include:

• Clients are facilitated to make informed choices, on how to achieve their own

goals through the use of existing community resources that meet their needs.

• Clients enjoy independence and autonomy residing in the community with

their families.

• Maximisation of clients’ potential by involving them actively in the needs

identification, assessment processes, goal-setting as well as the development

of the individualised care plan.

• The services provided are appropriate to, and are properly coordinated and

integrated to meet the individual needs of the clients.

• Continuity of care made possible by facilitating access to services for the

clients.

• Caregivers’ stress and burden in caring for the clients is alleviated through

therapeutic interventions and support services available in the community.

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3. Target Populations for Case Management Service

A few key populations have been identified by NCSS that would benefit

from case management service:

Multi-stressed Families

Most of the families in need of help would have multi-faceted problems

encompassing interpersonal, emotional, financial, health and social factors. These

problems are usually intertwined and often manifest over a period of time that

require close monitoring and intervention. The services stated in the care plans

addressing the identified goals have to be coordinated and integrated to facilitate

the family cope with the crisis situations and build resilience to deal with future

crises. The main aim (goal of service) is to empower the clients by using their

strengths in handling crises so as to develop competence in their lives.

Post Suicide and Crisis Cases

Currently, the social services available to this group of clients are

fragmented and not properly coordinated. The clients would be referred to the

medical social workers upon admission to hospitals for attempted suicide. They

would be followed up by the medical social workers for a period of time,

thereafter, referred to the nearest FSCs for follow ups. The FSCs are usually

centre-based and would discharge clients should they default in their counselling

sessions. Discontinuity of care could result in future suicidal attempts especially

when the clients are still emotionally distressed and are in need of intensive

counselling. The goal of service is to ensure continuity of care for clients upon

discharge from hospital by providing continued support and working through

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those issues that are part of the suicidal behaviour. This helps to reduce the risk

of such behaviour.

Family Violence Cases

Family is always regarded as the main building block of a society; it is

always believed that individuals should continue living with their families as far

as possible. Hence, victims of family violence choose to and are usually

encouraged to return to their families. In fact, they regard it as a punishment for

being a victim by not being able to return to their natural homes. In view of the

dysfunctional and constraining relationships existing between the perpetrators and

the survivors, this group of clients needs long-term close monitoring and

counselling to break away from the family violence cycle. The goal of service is

to empower the family by facilitating family members change constraining

relational styles, and develop skills to cope with stress that puts them at risk of

using violent behaviour.

Youth-at-risk

This group of clients usually exhibits behavioural problems at school, at

home, and in the community. They are consolidating their identity at a point of

transition and hence, are vulnerable to the identity crisis stage, searching for their

own identity and therefore, are susceptible to intrapersonal, interpersonal and

systemic stress. Without proper guidance, they can develop inappropriate

personality styles and behaviours. Currently the services available to them are

fragmented and not properly coordinated, even overlapping at times. The goal of

service is an effective case management with the adoption of multi-disciplinary

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approach where the case management links up the different system involved like

the school, the family and the community to facilitate them in developing

resilience to cope with stress at multiple levels.

People with Disabilities

People with disabilities can be categorised according to the nature of their

disability like physical, mental, psychiatric and multiple disability. In view of

their complex medical and psycho-social conditions that lead to complex needs,

they require key workers with long-term supportive relationships to assist them to

identify, secure and sustain a range of internal and external resources for their

independent living in the community. The goal of service is to ensure continuity

of care for this group of clients especially when they are unable to have access to

services that are vital to their community independent living.

People with HIV/AIDS

This group is usually left unheard and unnoticed due to myths and social

stigma attached to their health condition. Hence, they are often neglected by the

general public as well as the social service sector. They are left on their own to

access services in the community which are scarce. The issue of continuity of

care can be facilitated through advocacy. Their caregivers also need physical as

well as emotional support services in the community. The goal of services is to

recognise their needs to live in dignity in the community with properly

coordinated and integrated services catering to their needs and goals of life.

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Elderly with Multiple Needs

This group of elderly is characterised as poor, frail and non-ambulant with

chronic medical conditions and weak community support. Most of them are

ignorant of the existing services and hence have no access to these services that

maintain them in the community. Repeated hospitalisation that characterised their

lives can be avoided with a proper coordination and integration of appropriate

services and support in the community. For those elderly who have family

members staying with them, their caregivers also face considerable stresses and

need community resources and social support. The goal of service is to maintain

this group of clients in the community for as long as possible, with the appropriate

quality of life, by reducing hospital admissions as well as the stress levels of the

caregivers.

Reformed Offenders

This group of “offenders” often faces difficulty in re-integrating back to the

society due to external and internal factors like lack of opportunities and

acceptance by society as well as lack of appropriate skills to cope in the worlds of

work and society. The goal of service is a seamless transfer from incare to

aftercare facilitated by access to services as well as individualised support. The

goal for this group of clients is to get back on their feet in society, fulfilling their

personal and social responsibilities instead of committing criminal behaviours.

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4. Practice Functions of Case Management Service

The five core practice functions of an effective case management service

are as follows:

Assessment

A collaborative process where the case manager and the client cooperate in

the collection, analysis and prioritisation of information pertaining to identified

goal that address the needs of the latter. It is a positive concept that seeks to

identify clients’ strengths for growth and development besides recognising their

limitations and gives the clients the right to exercise freedom of choice in

decision-making. It is holistic as it covers the biological and psychosocial

functioning of the clients; and is comprehensive for it taps on clients’ capacities

and social networks, and human services in the community to meet identified

needs.

Planning

A systematic and participatory process where the case manager and the

client establish an Individualised Care Plan (ICP) which identifies and prioritises

goals, and develops activities and services to achieve these clearly defined goals.

As the ICP lays out the roles, activities and timelines of each actor, it becomes a

tool for the case manager to monitor and evaluate the implementation of goals and

objectives with its accountability characteristic. The ICP should be client-centred

and flexible to cater to client’s changing needs and abilities over time. Hence,

there is a need to review the care plan periodically to incorporate any changes or

new developments. It should also include discharge and follow up planning when

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the clients’ needs are all met, their physical, medical and psycho-social situation

has stabilised without any new needs arising, and clients (together with their

significant others) are coping well in the community.

Intervention

The implementation of the ICP, which determines the success of case

management, can be carried out in two ways, direct and indirect.

The six direct roles of case manager are:

• Implementer – This role is usually adopted during crises when clients are

immobilised and unable to cope with the situations.

• Teacher/Instructor – A strategy used in developing skills of clients to move

towards autonomy and independence.

• Guide/Collaborator – Clients are being guided by the case manager through

the collaborative process of obtaining services and supports to fulfil their

needs.

• Processor – Case managers help clients to identify alternatives and choose

appropriate services and supports.

• Information Specialist – Case Managers build up their resource databases for

clients’ access.

• Supporter – Case managers supporting clients to achieve self-advocacy.

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The six indirect roles of case manager are:

• Broker – Case managers connect clients to community services that

appropriately and adequately address their needs.

• Linkage – A strategy used to connect clients to services that assures utilisation,

e.g. referrals.

• Coordinator – service coordination at the client level i.e. services are

coordinated in a way that respond to clients’ needs.

• Case Advocacy – used when the identified agencies not willing to provide

services for the clients.

• Social Network Builder – Clients’ social network is a significant source of

support that should be built upon for it complements the formal human service

delivery systems.

• Technical Assistance and Consultation Provider – Case managers contribute

by making agencies responsive to the changing needs of clients in terms of

developing new programmes.

Monitoring

An active and fluid process implemented as a means of tracking the

implementation of the care plan to ensure continuity of care. Case managers use

monitoring to determine the extent to which the ICP is being implemented

appropriately; the achievement of objectives of the ICP; the outcomes of the

services and supports; and to identify new clients’ needs that require a change in

the ICP.

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Evaluation

Evaluation focuses on whether activities spelled out in the ICP are

producing positive, beneficial and desirable outcomes. It is necessary for

accountability to the clients, the funding source, and policymakers. Quality of

services is measured to ensure that they conform to generally acceptable standards

of good practice. This, in a way, ensures that limited resources are utilised in a

cost-effective way.

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5. Key Components of Case Management Service

Any agency that aims to provide case management services should take

into consideration the following essential components:

Models of Case Management

The different models of case management demonstrate that case

management is a flexible process as there are different ways in service delivery.

Models of case management focus on defining the organising principles i.e. role-

based, organisation-based or responsibility-based case management.

• Role-based Case Management is characterised by the role of the designated

case manager. The case manager meets all the needs of the client through a

single point of access by assuming a broad set of responsibilities including the

link to variety of needed services, provider of therapeutic care, monitoring of

the efficiency and quality of services, etc. The strength of this model lies in

the close involvement of the case manager that promotes strong relationship

with the client and the weakness being the large caseloads.

• Organisation-based Case Management is determined by the organisational

structure i.e. the way in which the services are arranged and delivered. The

case manager meets multiple needs through a single point of access, with one

location for service delivery. This model provides comprehensive case

management where case managers’ responsibilities range from coordinating

services to leading a group of professionals who provide services to the client.

The strength of this model being the holistic approach where assessment is

multifaceted and plan is individualised and hence easily monitored. The

weaknesses include the problem of resource availability in the organisation,

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the less engagement of the client’s family in the helping process, and the

danger of client not growing beyond the environment that he is accustomed to.

• Responsibility-based Case Management emphasises the long-term

involvement of the case manager, the coordination of services, and the

empowerment of the clients by holding an individual or a team accountable for

the care of the clients. The model allows case management responsibilities to

be assumed by various individuals or groups. The strengths include cost

effective service delivery, the involvement of the community, and promotion

of independence. The weaknesses lie with the designated case managers who

may not have the clients’ best interests at heart, may not have the necessary

expertise, or may be ineffective in monitoring service provision.

Professional Competency

The competency of a case manager depends largely on the model of case

management adopted, the skills proficiency and the target population. On the

whole, the case manager has to be a qualified nurse or a social worker with

background information as well as knowledge of the existing community

resources for the target group that he/she is serving. In view of the breadth of the

knowledge base required for effective case management practice, there is an on-

going need for continuing education and training which ensures a minimum

baseline of practice knowledge for the case managers. Hence, the in-service

training should be a combination of basic core content with topics that emerge

from the day-to-day operations.

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Networking with Other Agencies

As the key role of a case manager is to provide coordinated and integrated

services in the community so as to ensure continuity of care, it is paramount for a

case manager to establish networking with those service providers in the fields of

counselling, home help, support, day care, rehabilitation, vocational/sheltered

workshop, etc. This would facilitate in advocating and linking services for the

clients. In addition, case managers also need to build up close network with those

agencies that will refer clients to them like hospitals, Family Service Centres

(FSCs), Community Development Centres (CDCs), other social service providers,

etc so as to reach out to the target populations.

Programme Evaluation

Agencies are also encouraged to have in place a self-evaluation and audit

system in order to gauge the effectiveness and impact of case management so as

to ensure a high standard of service delivery pertaining to their clients’ needs.

Evaluation should cover the following:

• Programme effort that assesses the type and quantity of programme activities

• Programme effectiveness that addresses whether or not the intended beneficial

outcomes or unintended consequences have occurred as a result of programme

effort

• Programme efficiency that attempts to determine the relative costs of

achieving outcomes

© National Council of Social Service 2004

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6. References & Useful Links

Case Management

Moxley, D. P. (1989). The Practice of Case Management. California: Sage Publications.

Rothman, J. & Sager, J. S. (1998). Case Management: Integrating Individual and Community Practice. US: Allyn & Bacon.

Saleebey, D. (2002). The Strengths Perspective in Social Work Practice. US: Allyn & Bacon.

Vourlekis, B. S. & Greene, R. R. (1992). Social Work Case Management. New York: Aldine de Gruyter.

Woodside, M. & McClam, T. (1998). Generalist Case Management: A Method of Human Services Delivery. US: Brooks/Cole Publishing Co.

http://www.facs.gov.au/internet/facsinternet.nsf/aboutfacs/programs/house-newsaap_casemankit.htm

Multi-stressed Families

Methodist Welfare Services. (2003). Standard Operating Procedures (SOP) on Case Management for Family Service Centre.

http://www.aic.gov.au/conferences/crimpre/markham.pdf

http://www.strengtheningfamilies.govt.nz/Publications/PDFs/summary-analysis-final-meeting-forms.pdf

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Post Suicide and Crisis Cases

http://www.currentpsychiatry.com/2003_08/0803_suicide.asp

http://www.djj.nsw.gov.au/pdf/publications/Forms/Management%20of%20Suicide%20and%20Self-harm%20In%20JJCs.htm#_Toc17620607

Family Violence Cases

http://www.aic.gov.au/conferences/probation/kirk.pdf

http://www.csip.nebraska.edu/notes/famviolenceoverarchingthemes.htm

Youth-at-risk

Http://www.aforts.com/colloques_ouvrages/colloques/actes/interventions/herriger_norbert.doc

http://www.ncjrs.org/html/ojjdp/summary_comp_resp

People with Disabilities

Belcher, J. R. (1992). Plan Implementation and Coordination: Clinical Case Management with the Chronically Mentally Ill in Vourlekis, B. S. & Greene, R. R. (eds). Social Work Case Management. New York: Aldine de Gruyter.

Hare, I. & Clark, J. P. (1992). Case Management Assessment in School Social Work and Early Intervention Programs for Disabled Infants and Toddlers in Vourlekis, B. S. & Greene, R. R. (eds). Social Work Case Management. New York: Aldine de Gruyter.

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Harris, N., Williams, S., & Bradshaw, T. (2002). Psychosocial Interventions for People with Schizophrenia: A Practical Guide for Mental Health Workers. New York: Palgrave Macmillan.

Kaplan, K. (1992). Linking the Developmentally Disabled Client to Needed Resources: Adult Protective Services Case Management in Vourlekis, B. S. & Greene, R. R. (eds). Social Work Case Management. New York: Aldine de Gruyter.

http://www.epip.org.sg

People with HIV/AIDS

Kaplan, M. (1992). Care Planning for Children with HIV/AIDS: A Family Perspective in Vourlekis, B. S. & Greene, R. R. (eds). Social Work Case Management. New York: Aldine de Gruyter.

http://hab.hrsa.gov/special/integrating.htm

http://www.cumberlandcountyhiv.org/cms.htm

http://www.msh.org/news_room/news_releases/pdf/CBHC_Ch14_web.pdf

Elderly with Multiple Needs

NCSS. (2001). Community Case Management Service for the Elderly: Service Model.

http://www.geriatrictimes.com/g010531.html

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© National Council of Social Service 2004

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Reformed Offenders

http://www.carenetwork.org.sg

http://www.doleta.gov/sga/rfp/rfp03-09_attach.pdf