Case Management is a comprehensive process that helps the older person gain access to and coordinate appropriate services, benefits and entitlements through the use of a standardized process of assessment and reassessment, care planning, arranging for services, follow-up and monitoring, and discharge.
A Standard Assessment is the collection of information about a person’s situation and functioning and that of his/her caregivers which allows identification of the person’s specific needs and problems in the major functional areas.
A Care Plan is a formal agreement between the client and case manager and, if appropriate, the client’s caregivers regarding client problems identified, goals to be achieved, and services to be pursued in support of goal achievement.
Implementation of Care Plan (arranging and authorizing services) is achieved by contacting service providers, conducting case conferences, and negotiating with providers for the delivery of needed services to the client in the manner prescribed in the care plan.
Follow-up and Monitoring is ongoing and planned contact with the client and service providers to ensure that service delivery is meeting the client’s needs and being delivered at the appropriate levels and quality.
Reassessment is the scheduled re-examination of the client’s situation and functioning and that of his/her caregivers to identify changes which occurred since the initial assessment/last reassessment, and to measure progress toward goals outlined in the care plan. In so doing, a determination is made as to whether the care plan needs to be updated and the pattern of service delivery changed.
Termination or Discharge is the ceasing of case management as a result of the client’s requesting discharge, attaining the goals described in the plan, needing a different type of service other than case management or ineligibility for the service.
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