Under 1 Roof Case Coordination 30/01/2017 Under 1 Roof Brisbane 1 - - PowerPoint PPT Presentation

Under 1 Roof Case Coordination

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• 1. Welcome
• 2. Case study
• 3. Discussion
• 4. Activity: writing a brief about case

coordination

• 5. Input on case coordination
• 6. Activity: the challenges involved in

collaboration

• 7. Input on facilitation
• 8. Synthesis and closing activity

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In your table group, generate answers to the following questions:

 What is your assessment of the situation?  What are the strengths and challenges in this case study?  In particular, what are the coordination challenges?  What goals would you establish in this situation?  What would you include in a housing and support plan?  How would you make sure the agencies involved understand the

plan and the approach to be taken?

 What skills will people involved in her care need to make use of as

they put the plan into action?

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 (Individuals) Write down one reflection of your

• wn about why you think case coordination

approaches might be important?

 As a team, you have been asked to write a brief

to your manager about whether your agency should participate in a case coordination group.

 What would you include in a definition of case

coordination?

 What rationale for case coordination work

would you provide?

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 Services can be specialised and people may need

more than one thing

 Resources, service providers – dispersed and

decentralised (place-based, patterns of funding)

 Resources can be too few:

• Reduce waste
• Stitching together what is available

 The impacts of vulnerability.

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Case coordination includes communication, information sharing, and collaboration, and

• ccurs regularly with case management and
• ther staff serving the client within and

between agencies in the community. Coordination activities may include directly arranging access; reducing barriers to obtaining services; establishing linkages; and other activities recorded in progress notes.

Department of Health NY Case Coordination and Case Conference (website, 2015)

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 Case coordination or care coordination is a process utilised in a variety

• f contexts including aged care and health.

 Case coordination often emerges because most service systems have

multiple parts and because people inevitably have varied and unique needs.

 In addressing homelessness, it is usually essential to integrate a

number of resources, elements and contributions.

 Case coordination is an approach that brings together the support,

housing and other assistance a person needs in ways that increase the likelihood of a permanent exit from homelessness or the sustainment

• f a tenancy at risk.

 Case coordination is a way of working that strives to make the

homelessness system work for people and reduce the risk that they fall through the cracks simply because a support and housing plan is fragmented and loose.

 The challenge with case coordination is to bring together the best

possible mix of resources, support, housing options and other

• pportunities so that people no longer face a system that is too

complex to navigate.

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Case coordination is usually characterised by the following essential elements:

• A number of participants are involved
• Coordination emerges in the context that participants

depend on each other to carry out diverse activities that contribute to the care and wellbeing of a person

• Each participant needs adequate knowledge about their own

role, others’ roles, and available resources

• To manage all aspects of care, participants rely on an

exchange of information

• The integration of support activities has the goal of

facilitating the appropriate delivery of coordinated care to homeless people. Adapted from National Centre for Biotechnology Information (NCBI) http://www.ncbi.nlm.nih.gov/books/NBK44012/

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 Case coordination is the deliberate organisation of

supportive activities between two or more participants (including the person) involved in a person’s care.

 Case coordination aims to facilitate the appropriate delivery

• f specialist and generalist services to a homeless person so

they can exit homelessness and sustain a tenancy.

 Organising care involves the marshalling of personnel and

• ther resources needed to carry out all required support

activities, and is often managed by the exchange of information among participants responsible for different aspects of care. Adapted from National Centre for Biotechnology Information (NCBI) (2010) http://www.ncbi.nlm.nih.gov/books/NBK44012/

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From the standpoint of the service recipient, Service Coordination can accomplish three

• bjectives:



to connect service recipients to needed resources



to buffer the service recipient from the stress of navigating the bureaucracy



to enable service recipients to manage their own lives within the scope of their resources and abilities From the standpoint of the agency or service system, there are additional objectives:



to manage resources within defined limits to achieve cost efficiencies, effectiveness, and avoidance of preventable and unnecessary costs



to facilitate the delivery of service by coordinating the contributions of multiple service providers and scheduling services so that they are provided without any delay that might adversely affect the recipient’s condition



to avoid deterioration resulting in the need for more costly services by keeping a chronically or mentally ill service recipient connected to the agency so that medication and services will continue to be received



to monitor progress, or lack of progress, so that changes in treatment can be made in a timely fashion



to monitor outcomes to determine whether existing service protocols or practices need to be revised. Best practice brief Michigan University, No 13, 1999-2000, From case management to service coordination

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 Service providers learn from each other about

resources and offerings

 Service providers (front-line) are supported in

complex case work

 Service providers (front line) develop skills and

capacities to actually do complex case work

 Service providers develop skills and capacities to

coordinated and integrate resources and services.

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 A goal of care coordination is high-quality referrals

and transitions assuring that all involved providers, institutions and clients have the information and resources they need to optimise care.

 Elements of success:

• Assuming accountability
• Providing support
• Building relationships and agreements among providers

(including community agencies) that lead to shared expectations for communication and care

• Developing connectivity via electronic or other information

pathways that encourage timely and effective information flow between providers (including community agencies

http://www.improvingchroniccare.org/index.php?p=Care_Coordination_Model&s=353

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 Terminology:

• Service coordination
• Care coordination
• Case coordination
• Support facilitation
• Care facilitation

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 Responding to HIV  Health  Aged care  Acknowledged as a helpful input to a variety

• f client groups (older people, young people,

families, individuals)

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Social opportunities Community development Specialist homelessness Volunteering services Support services Mental health services Mainstream services Drug and alcohol Housing providers Volunteering Civic involvement Employment services Recreation opportunities Case Coordination Case Coordination Meeting Referral pathways Referral pathways Referral pathways Referral pathways

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All have some essential elements in common:

 Identification of clients/households  Assessment  Planning  Plan implementation and monitoring

http://www.improvingchroniccare.org/index.php?p=Care_Coordination_Model&s=353

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Key components of case coordination include:

 An assessment of the person with a focus on those factors

that indicate a person may be vulnerable to poor integration

• f services

 Developing and agreeing on a support and housing plan  Identifying key roles and resources and clearly allocating

responsibilities

 Clear identification of key worker/ lead agency  Communicating the plan to all participants including the

person

 Implementing the plan  Monitoring and adjusting the plan and identifying

coordination failures if they arise

 Continuing implementation  Measuring and evaluating outcomes.

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 The person has multiple, intersecting needs  The person has experienced episodes or long-term

homelessness

 The person has experienced one or more examples

• f a housing placement deteriorating or ending,

resulting in homelessness

 The person is currently housed and their tenancy is

failing or vulnerable

 The practitioner involved with the person would

find peer support and multi-agency input beneficial because the situation is complex

 To raise the profile of a client within the system.

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 An informed consent tool, to secure informed

consent in writing

 Demographic information  An assessment of health, housing and support

needs

 An assessment of other support services involved

to assist with the coordination of those services.

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 Essential part of the process  Need to work with your own agency to ensure you

are working within their requirements

 Need to stay abreast of changes to law  De-identified presentations: to learn and make

progress without consent?

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 The worker’s relationship with the client  The way that case coordination is explained to the

client

 A worker’s ability to motivate clients to consider the

potential benefits of case coordination

 A willingness by workers to continue to explore the

possibility of integrated case coordination with the client at other times, even if they are reluctant at first.

 The direct provision of assistance by the referring

agency even if consent is not achieved, as a basis for continuing to build a trusting relationship which could be an important resource into the future (up front, continuous approach)

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 Inform the client of their legal rights  Identify the agencies that information will be

shared with

 Outline the process that will be followed to assist

the person with their housing and support needs

 Explain how the person can get access to the

information that is recorded about them

 Reassure the person that they have full access to

the services provided by the referring/assessing agency even if they don’t consent to case coordination.

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 Case conference  Case review  Leadership  Learning

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 Skills: how we do the work we do  Frameworks: how we think about the work

we do (example structures/relationships)

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 Consider personal, interpersonal,

• rganisational and structural challenges

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 Agencies may work from diverse paradigms and perspectives  Organisations are varied in size  Practitioners bring diverse levels of experience and different backgrounds  There are diverse beliefs, assumptions and ideologies among practitioners  There is competition for funds  There can also be pressure to compete for organisational profile and

reputation

 All workers involved (front-line and managers) have limited time to

contribute to coordination activities

 There is a high volume of clients and the demand on each agency for

services is significant

 There are natural tensions between different roles and functions  The context of service provision is changing  There can be tensions between ideas and methods which appear to be

binary (either/or) propositions such as:

• Privacy versus coordination
• Assertive practice and outreach versus self determination
• Housing first versus a pathways approach to ending homelessness
• Recovery/vulnerability

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 Ongoing process, a way of working  Shifts focus to shared client work  Beyond interagency networking, to creating structures

that let us actually do the work we need to do to assist clients

 Acute sense of purpose

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 The most important role  Skilled role  An opportunity to develop  Not everyone is a natural facilitator  Building capacity to facilitate  Building capacity at a coordinated approach.

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 Direct involvement  Specific expertise  Community of practice.

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Cam Barker The Vivid Method

 Design and plan the group process, and select the tools

that best help the group progress towards that outcome.

 Guide the group process to ensure that:

• There is effective participation.
• Participants achieve a mutual understanding.
• Their contributions are considered and included in the ideas,

solutions or decisions that emerge.

• Participants take shared responsibility for the outcome.

 Ensure that outcomes, actions and questions are properly

recorded and actioned, and appropriately dealt with afterwards. From Mindtools.

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 Facilitation – critical role  Secretariat support – provided through philanthropy at this

stage– also critical

 Consistency of secretariat role critical  Spreadsheet –simple  Data system limitations  Share data platform – remains the dream but still lots of debate  Each client reviewed at each meeting  If you can’t attend it is encouraged that you send through

updates

 Revisit mentors : to help support new people and champions

share information about U1R within agencies and are a contact point for referrals in via participating agencies.

 Revisiting internal champion for each agency  Managers rostered to attend – a challenge because they are so

busy.

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Persistent Assertive Protective Vulnerability

 Maintain the most significant focus on client work which helps to keep the

• verall purpose clear: helping people and ending homelessness

 Choose some well defined projects that exercise the capacity of the

agencies to work together and that strengthen trust and capacity (such as case coordination meetings and the bric lounge project).

 Draw people together in shared learning and development experiences so

that they build shared frameworks and build their identity as a learning community open to ways they can work better

 Build a culture of celebrating successes and reflecting on where practice

could be better. This builds a strong platform for action and maintains a focus on the future as a resource for improving things all the time. It also reduces competition because agencies begin to share the view that there are things we can do better and they have the confidence to be honest about what those things are within a wider process of dialogue.

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 Assessing vulnerability –tension between strengths practices

and really nailing the problem

 Detailed support planning  Documentation to support good outcomes reporting  When to exit to case coordination – sometimes too early  Sustainment of tenancies and tracking clients – it is easier if

people are housed within OSHS compared to the private rental market and then it depends if support is ongoing.

 Senior support – coming to the meetings as managers are

very busy

 Quality facilitation is critical – invest in this becoming a

stronger skill in your region

 Efficiency in verbal reporting and getting through all the

clients in a detailed enough way – about 20 per meeting

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 It is all about relationships  It is all about structures  More true to say: It is all about structures and

relationships and that robust structures can support the work being done even where relationships are a challenge

 Beyond binary ways of thinking and towards

synthesis

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 What will you go away and think about some

more?

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