This process outlines the steps to implement an outcome-based approach to support(care) coordination. It ensures:
trends, emerging best practises and improvements to services and supports offered to clients and families
the key issues when measuring outcomes are identified
that how to use outcome data is considered.
All clients receive a coordinated service response which involves the family/carer and significant others, where relevant and appropriate, the service team and appropriate external services based on the agreed client support plan.
Rationale
The need for and level of support coordination for a client is determined in the development of the support plan.
Where a range of issues is being addressed, it is more likely that greater coordination is needed as more services are involved in supporting the client.
For some particularly vulnerable clients, responsibility may sit with a government body even though the support is provided locally.
Key elements of support coordination include:
coordinated support and planning with the client
family involvement in decision making
monitoring and reviewing of coordinated supports
documenting of coordinated supports provided
coordinated family/carer/guardian support and planning.
The roles, responsibilities and pathways of communication between each of the responsible parties/agencies/staff in the client's support plan need to be clear.
A staff member responsible for coordinating the support plan should be allocated.
Coordination of services needs to be carefully negotiated to ensure all parties involved acknowledge the role of coordination and agree to fulfil the actions they are responsible for.
Opportunities must be provided for carers to engage in the process of information exchange, for example, through staff meetings, team meetings, inter-agency meetings and meetings with the client and their family/carer.
Confidentiality and privacy throughout the exchange of information are crucial.
Where responsibility for coordination sits within another agency, agreement to provide services should also include discussion on how coordination will occur and how coordination issues will be managed.
Family involvement in decision making
It is important to involve families in decision making in relation to the service being offered. This requires the family to be offered the opportunity for active involvement.
The family needs access to relevant information about other services and any legal issues that may arise.
Where another agency has responsibility for case coordination and does not have a similar approach to family involvement, we will actively advocate for family involvement.
Monitoring and reviewing client support coordination
If our service coordinates the family support plan, it needs to monitor and review its family support coordination to ensure it meets the client's needs in the most appropriate manner and within the planned timeframe.
If an external agency is coordinating the client support plan, then we still need to monitor and review our own activities, in conjunction with the client on an ongoing basis.
We will also participate in the coordinating agency’s review of support coordination.
Documenting client support coordination
The roles and responsibilities of all parties should be documented within the support plan.
Any case conferences or other meetings held between agencies to discuss a client's case should be minuted and placed in the case file.
Process - Step by Step
Start
Step 1.Assess
If a client has care and support needs, undertake an assessment of their needs to better identify what support is required.
The duty to offer or arrange an assessment applies regardless of any other concerns or queries,
The outcome of the assessment is to provide a full, but proportionate, picture of the individual’s needs so we can provide an appropriate response at the right time to meet the level of the individual’s needs.
Step 2.Discuss
Our support plan is person-centred and the client must have every reasonable opportunity to be involved in the planning to the extent that they choose and are able.
HWH actively involves the client (and where required their family/guardian) in all discussions throughout the process to ensure the support plan is holistic and takes account of their wishes, feelings, strengths, needs and aspirations.
Step 3.Plan
For effective planning, support/care coordinators should adhere to the following recommendations:
be constructive and focused on the development of the individual
be person-centred and contribute towards enhancing the individual’s quality of life
promote and emphasise the accepted core principles, especially independence
be formulated in collaboration with the individual and - where appropriate - the family
have a clear and systematic structure, in a format understood by all concerned
remain confidential and owned by the client
entail objective recordings based on observed facts
cover all major areas of care, as established through needs assessments
include specific objectives and goals, together with timescales for their achievement
highlight a nominated person responsible for implementing agreed goals
be properly monitored/reviewed and open to revision as circumstances change.
Step 4. Coordination
Coordination includes activities necessary to obtain the support and services identified in the support plan. This includes:
linking the clients to services, support and assisting them in identifying service/allied health providers as needed
the support coordinator also ensures that the services and supports remain within the allotted budget and monitor the delivery of services
the support coordinator will make a clear distinction between acting as a resource and providing advocacy on behalf of the family
the support coordinator provides information, supports individuals in advocating for themselves, and links individuals to advocacy resources but will not serve as the advocate for the family.
Step 5.Review
When reviewing, we review the plan and consider if it is helping the person to meet their needs. We consider these broad elements:
Has the client's circumstances and/or care and support or support needs changed?
What is
working in the plan
not working, and
what might need to change?
Have the outcomes identified in the plan been achieved or not?
Is there any room for improvement?
Is the client's personal budget enabling them to meet their needs and the outcomes identified in their plan?
Are there any changes in the client's informal and community support networks which might impact negatively or positively on the plan?
Is the client, family, carer, independent advocate satisfied with the plan?
If meeting the previously mentioned deliverables are delayed due to
the client and their family/carer failing to attend meetings,
participate in mandated contacts,
allow access to the home for visits, etc.,
the support coordinator notifies the client and family/carer that non-compliance is recorded.
If this continues, the support coordinator supervisor notifies the designated personnel and follows up with the client and their family/carer.
Ongoing lack of cooperation with the client and family/carer may result in termination of services.
