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

Under 1 Roof Case Coordination 30/01/2017 Under 1 Roof Brisbane 1

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 30/01/2017 Under 1 Roof Brisbane 2

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? 30/01/2017 Under 1 Roof Brisbane 3

 (Individuals) Write down one reflection of your own 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? 30/01/2017 Under 1 Roof Brisbane 4

 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. 30/01/2017 Under 1 Roof Brisbane 5

Case coordination includes communication, information sharing, and collaboration, and occurs regularly with case management and other 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) 30/01/2017 Under 1 Roof Brisbane 6

 Case coordination or care coordination is a process utilised in a variety of 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 of 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 opportunities so that people no longer face a system that is too complex to navigate. 30/01/2017 Under 1 Roof Brisbane 7

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/ 30/01/2017 Under 1 Roof Brisbane 8

 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 of 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 other 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/ 30/01/2017 Under 1 Roof Brisbane 9

From the standpoint of the service recipient, Service Coordination can accomplish three objectives: 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 30/01/2017 Under 1 Roof Brisbane 10

 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. 30/01/2017 Under 1 Roof Brisbane 11

 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 30/01/2017 Under 1 Roof Brisbane 12

 Terminology:  Service coordination  Care coordination  Case coordination  Support facilitation  Care facilitation 30/01/2017 Under 1 Roof Brisbane 13

 Responding to HIV  Health  Aged care  Acknowledged as a helpful input to a variety of client groups (older people, young people, families, individuals) 30/01/2017 Under 1 Roof Brisbane 14

Social opportunities Community development Referral Referral pathways pathways Specialist homelessness Volunteering Case Coordination services Support services Mental health services Case Coordination Meeting Mainstream services Drug and alcohol Housing providers Volunteering Referral Referral pathways pathways Civic involvement Employment services Recreation opportunities 30/01/2017 Under 1 Roof Brisbane 15

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 30/01/2017 Under 1 Roof Brisbane 16

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 of 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. 30/01/2017 Under 1 Roof Brisbane 17

 The person has multiple, intersecting needs  The person has experienced episodes or long-term homelessness  The person has experienced one or more examples of 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. 30/01/2017 Under 1 Roof Brisbane 18