Case management

Case management is the term used to describe ‘a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost effective outcomes’. (Case Management Society of Australia [2006])

It is is an ongoing service that aims to strengthen outcomes for the older person and, where relevant, their carer or family, through integrated and coordinated service delivery. By using a case management approach an elderly person’s quality of life is enriched and inappropriate admission to residential aged care avoided.

Strengths and needs assessment

A strengths and needs assessment is a planned way of gathering information. This information is used as a basis for deciding on the best way to respond to the support needs identified by the elderly person and their family.

Janet has carefully developed her own assessment tools, which evaluate the strengths and needs of the client. Together with information gleaned from the ACAT assessment, where available, this assessment will be the foundation for development of a care plan.

Care planning

Following the assessment, a care plan will be developed in dialogue with the client. This plan will have regard to relevant medical diagnoses, mobility, continence and any cognitive issues the client may have, and may include referral for government-funded services, the purchase of privately provided in home care, respite care either in the home of the person or in a residential respite facility or permanent residential aged care placement.

Information provision

An essential part of part of case management is the provision of accurate, reliable, timely and relevant information. Information provided by this service may include:

  • An explanation of the aged care system in NSW.
  • Information regarding appropriate in home services, including the range of services, eligibility, how to access those services, likely waiting times, fees etc.
  • A comparison between packaged care and stand alone in home services.
  • Information/ recommendations regarding suitable Residential Aged Care Facilities based on individualised research.
  • Information on financial aspects of entry to Residential Aged Care Facilities e.g. bonds, fees.
  • A comparison between residential aged care i.e. nursing home or hostel care and home based care.


As a part of case management this service will:

  • Ensure appropriate and timely referrals for in-home services are made and provide ongoing coordination of in home services.
  • If residential care is necessary, research suitable facilities, support clients in the application process, liaise with facility managers regarding vacancies and support clients to transfer to a facility.


As a part of case management this service will advocate on behalf of the client. This may involve speaking, acting or writing on behalf of the elderly client
Advocacy, literally ‘a voice beside’, is ‘the process of standing alongside an individual who is disadvantaged and speaking out on their behalf in a way that represents the best interests of that person.’ (The Institute for Family Advocacy and Leadership Development)
Advocates are not impartial because they work entirely from the perspective and interests of the older person for whom they are advocating. Their role is to assist older people by representing their wishes.

Counselling and support

The loss of independence for a client and associated life changes may be accompanied by emotional challenges for most older people. As an accredited social worker Janet is able to provide supportive counselling to clients.

Monitoring and review of service provision

The Case management agreement decided with you may include monitoring and reviewing services to ensure they are meeting your needs as they currently are or changing over time.