4.3.4 Case Management

1. Introduction

The term case management refers to the assessment and review process for adults and older people with care and support needs.

The Community Assessment Service provides assessment and support for people whose health and social care circumstances requires care and support. 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 the person as well as involved professionals who may include occupational therapists, physiotherapists, community nurses, doctors and speech therapists etc  (see also Assessment).

The assessment will be carried out and coordinated by a social worker who would liaise with other relevant parties which could include housing, leisure, employment, voluntary sector services as relevant (see Integration, Cooperation and Partnerships).

The person, 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 people / family members to continue caring for the person, 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 people with care and support needs to live safe and independent lives, as far as possible. This includes encouraging positive risk taking (see Personalisation and Risk Assessment);
• encourage independence through innovative ways of supporting people, 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 person and their carer;

3. Responsibilities of the Community Assessment Service

The Community Assessment Service is responsible for a number of different assessments, including:

• assessments of need under the Care Act: 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 person 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);
• assessments carried out under the Mental Capacity Act 2005 (see Mental Capacity);
• Deprivation of Liberty and best interest assessments (see Deprivation of Liberty Safeguards);
• carers assessments (see Assessment);
• financial assessments (see Charging and Financial Assessments);
• panel assessments;
• continuing care assessments (see Continuing Care (NHS));
• assessment and management of adult safeguarding cases and safeguarding investigations as required (see Adult Safeguarding);
• care and support planning: the Community Assessment Service is responsible for ensuring that services deliver to meet the assessed care and support needs, to enable people to 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 person’s home or placement setting (see Care and Support Planning).

See Eligibility chapter for criteria to receive services.

4. Timescales, Outputs and Outcomes

In order to avoid delays to people and carers receiving assessments and / or services, work within the Community Assessment Service 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).

4.1 Timescales

The following timescales apply:

• full Care Act assessments will be completed within 28 days of receipt of initial contact;
• care and support provided according to the person’s needs and level of risk.

4.2 Outputs

Outputs from the Community Assessment Service are:

• assessments of need under the Care Act;
• ensuring care and support (for people) and support plans (for carers) are in place (see Care and Support Planning chapter);
• multi-disciplinary / multi-agency assessments;
• mental capacity assessments;
• Community Deprivation of Liberty process, which includes assessments, review, care and support plan, prioritisation and restriction tool, mental capacity assessment and best interest decisions, CoPDoL11 and CoPDoL3;
• Section 42 enquiries: risk assessments and protection plans;
• carers assessments and support plan;
• continuing health care checklists;
• funding applications, including indicative personal budget calculations;

• 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.

4.3 Outcomes

Outcomes from the Community Assessment Service are :

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

5. Further Reading

5.1 Relevant chapters

The Person’s Care and Support Pathway: Local Teams and Services

Assessment

Eligibility

Charging and Financial Assessment

Care and Support Planning

Community Assessment Service 

Care and Support Service