The case plan meeting: A step-by-step guide

A case plan (sometimes called a care plan) states what needs to be done and who needs to do it. Case plans can also include:

• the assessment plan (which might include an investigation)
• Support and management plan
• Out of home care plan
• A plan for restoration, reunification or restitution
• A protection plan
• An evaluation system

Case plan form (.doc file)

Before the meeting

1. Check your organization's procedure and frameworks, and compare it with this one.
2. Your organization will probably have a case plan form, because it must be recorded.  Get a copy of the form. The form will generally follow the format of the meeting, so you will mostly be talking about what to fill in the form.
3. Get the statement of the admission assessment from the admitting officer.
4. Figure out what information (if any) you need to give the client in the meeting.

Meeting with the client

1. Start by setting the tone of the meeting. Establish an appropriate rapport; being friendly and fairly informal will make things go much more easily. (And if any conflicts do arise, it's your job to resolve them.)
2. Inform the client of anything they need to know.
1. Explain clearly your role.
2. Tell the client and relevant others about how case management works and their role in the process.
3. Make sure they understand their rights, including how to appeal and complain.
4. Clarify the purpose of the meeting, what you want to achieve in it, and the agenda items.
3. Start filling in the form as you go.
4. Clarify the purpose of the meeting, what you want to achieve in it, and the agenda items.
5. List other relevant stakeholders (e.g. client's significant others, immediate family and/or extended family, referring GP, insurers).
6. Identify any relevant family, community, cultural and ideological considerations.
7. List the full range of immediate, short-term and long-term needs of the client and related parties.
1. Explore the issues.
2. Identify and build on client strengths
3. Identify any risk factors and priority needs.
8. Decide on the overall direction of the case plan and the outcome you need to achieve. You will need to keep this in mind during implementation later on. Check the following:
   1. Decide how you will deal with any complex or high risk situations (if applicable)
   2. You might need to prioritize goals.
   3. Explore and define the rights of the individual, the family and the wider community, so that everybody involved has their rights protected.
   4. Explore and define the responsibilities of your organization.
   5. List the range of suitable interventions to meet your client's immediate, short-term and long-term needs. Have a range of strategies to address each goal. A range of strategies might also cover your options if anything goes wrong. You may need to have contingency plans in place.
   6. Check that it is a good use of resources because they may be limited.
   7. Check that the case plan matches your experience, workload and geographical location.
9. Define, negotiate, and get agreement on:
1. assessment of needs,
2. overall goals,
3. specific objectives as indicators of success.
4. strategies for getting maximum participation in the plan,
5. how you will use the expertise of relevant stakeholders and other service providers, and get them to agree to sets of responsibilities, which will be within their normal service guidelines. (For example, the medical practitioner will give normal medical consultations.)
6. what else needs to happen,
7. how you will monitor achievement of goals,
8. time-frames
9. how you will keep in touch,
10. how you will handle complex or high risk situations (you should have procedures or precedents to follow), and
11. resourcing (which normally means clarifying how services will be paid for).
12. Establish ways of monitoring and changing case plans. This will usually be through a regular review, although you should do a non-routine review if circumstances change radically.
10. Communicate with your client:
1. Inform the client of his/her the rights and responsibilities of your client, in simple language and make sure they understand them. The plan needs to focus on helping clients to set and achieve realistic targets for change or action and to take personal responsibility.
2. Ask the client to inform you of any difficulties that they have during implementation and give them your contact details.
3. Clarify how clients may inform you if they are are unsatisfied and how they could end or renegotiate the kinds of help they get.
4. Define what everybody involved is supposed to do and who they will be accountable to (include clients, stakeholders, staff and service providers).

Your homework after the meeting

Check that your draft plan on the form covers all needs. It will document the outcomes of your negotiation.

1. Decide how you will monitor the case plan. For example, how often will you check up? Who will you talk to?
2. Decide how you will change your case plan if you need to do so.
3. Make a list of your reporting requirements. These may be quite complex if you are responsible to people other than your supervisor. If you aren't the fieldworker who works with the client, you will need to select one who has the experience to handle those needs, who has enough time, and who is located near enough to the client.
4. Who needs to get a copy of the case plan?

Arranging specialist services

Your goal is to negotiate with stakeholders and service providers so that everybody agrees on what they are to do and understands what others will do.

First, you may need to get your supervisor to check your case plan if you are a junior worker or if your organization's procedures require it. (Junior workers usually have to clear their case plans with a supervisor.)

You are representing your client to the service provider, so you should discuss it with the client first.

You need to get maximum participation:

1. Get their agreement on overall goals, specific objectives, and implementation.
2. In some cases you might need to put contracts in place.
3. Explore and define any relevant organizational responsibilities.
4. Define what everybody involved is supposed to do and who they will be accountable to (include stakeholders, staff and service providers).
5. Get everybody to agree on:
• what needs to happen
• your indicators of success, and,
• how you will monitor achievement of goals, time-frames and resourcing.
6. Get them to take responsibility for their roles
7. Ask the service providers to inform you of any difficulties that they have during implementation and give them your contact details.
8. Identify boundaries and get agreement on them. These will often include:
• rights, roles, responsibilities, decision making processes, accountability and outcomes
• ways of addressing their experience, skills, values and development
• impact of statutory mandates on interventions, the client and significant others
• the impact of your value system on outcomes
• the impact of the client's value system
• information sharing
• how you will do further planning
• appropriate ways of resolving conflict

You will also have to mediate and/or resolve any conflicts in the process.