Case Management and Care Coordination in the remote setting

In a remote setting, the aged care coordinator becomes the Case Manager as well as the care coordinator, two tasks that consume much of the remote coordinator’s time. This is often primarily due to the need to assist a client with many of the administrative or facilitation tasks that would normally be carried out by the individual or their family in an urban mainstream setting.

For example, my mother has recently had a fall and will be staying with us for a few weeks while she recovers from a hip operation. In preparation for this, I organised the short-term hire of equipment to assist her in her recovery process. Together, my mother and I have discussed her discharge with the physiotherapist and I have alerted the local doctors clinic that her information will be forwarded to them on her discharge from the rehabilitation facility. We haven’t needed to use the services of My Aged Care (the portal for aged care assistance in Australia), however if we had needed to, we could have used the website or made a phone call and have outlined her needs.

Contrast this with an older person from a remote setting who does not have good English skills, whose family may have competing priorities, and where they may not have the knowledge of where to get equipment or have a home that is accessible. Their needs become so much greater as everything is harder for them and their family.

Although services desire older people to be more independent and play a larger role in organising their own care and support, the truth is, in many of the very remote regions, the level of English language, literacy and numeracy competency held by many consumers is low and results in the need for a greater time commitment in case management and/or social support. It is not just when things go wrong either, it’s in the day-to-day areas that many older people require support. While this is legitimate time spent on the care of an individual, the additional time will need to be reflected in an individual’s care plan and budget.

One area that appears to be confusing to coordinators is where Case Management starts and stops and when does it become care coordination or even social support? Well, this is my interpretation of the three areas – your organisation may have some different definitions and you should follow those, but if not, these thoughts might help clarify the question for you.

Case Management

The Case Management Society of Australia (CMSA) describes case management as:

“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 care”

(CMSA, 2004 in Coopers & Yarmo Roberts, 2006)

When providing case management, the coordinator needs to understand the holistic requirements of the consumer, their goals and preferences and also their overall health status. To do this, the coordinator will be checking on the consumer more frequently and gaining health status updates from health professionals. The case manager will respond to the individual’s changing needs, working with both the consumer and their family to ensure they receive the support they need to remain living independently or with their family.

For consumers with complex care needs the Coordinator may be liaising with a number of different stakeholders, arranging appointments, assessments and referrals on behalf of the consumer and alerting the clinic of health concerns. The coordinator may also be notifying the consumer of additional supports they may be eligible for and assisting the consumer to complete any relevant applications.

Care Coordination

Care coordination is about arranging the timing and delivery of services that have been identified in an assessment. In the Commonwealth Home Support Programme, for example, there is an implied amount of care coordination involved in delivering a service to a consumer.

An example of care coordination is where the My Aged Care assessor has referred a consumer to an organisation for support around meals and laundry. The coordinator will work with the consumer to identify personal preferences around food likes and dislikes, allergies or other special dietary requirements and preferred times for service delivery as these will most likely not have been explicitly identified by the referral. This information is then used to aid the delivery of care and support to the client.

Any additional needs that are identified by the organisation need to be referred back to My Aged Care for assessment.

Social Support

Social Support is the hands-on aspects of service delivery, assisting an individual with support needs identified in their care plan. For example, it could be assisting the individual with:

• Shopping – including writing their shopping list and planning their menu
• Banking – including helping the person to speak to banking personnel
• Communicating with agencies such as Centrelink or Legal Aid
• Reading and interpreting letters for them
• Helping to apply for pensioner discounts

This is not an exhaustive list by any means, however it gives you an idea of what it might entail and, of course, social support assistance will look different for each individual.

Program Relevance

With clients on a number of different programs it sometimes gets confusing about who receives case management from your organisation and who receives their case management from another entity.

To clarify then:

All consumers on a Home Care Package should have a case management plan developed by their service provider. The case management plan will identify the key stakeholders and services involved in supporting the plan. When preparing a client's Home Care Package case management plan, the coordinator will need to work with the consumer, and their family or carer if appropriate, to develop a goal-oriented care plan, develop an individual budget and engage with different service providers to purchase and/or access services that the consumer needs, according to the agreed care plan.

Home Care Package consumers are screened by My Aged Care, assessed by the Aged Care Assessment Team with the service providing both care coordination and ongoing case management, referring clients to relevant service providers and holding case conferences as required.

The Commonwealth Home Support Programme has an expectation that recipients have lower care support needs. The My Aged Care portal and service acts as the case manager, referring consumers to the relevant service providers for individual service types. Services provide for the referred care needs of the individual and refer back to My Aged Care if that individual’s needs increase.

Depending on your location, disability care recipients will receive case management support from either the relevant State or Territory office of Disability or from the National Disability Insurance Scheme. Changes to care provision or support needs should be referred back to the relevant case manager. The service provider will only provide care coordination in this instance.

Want to keep this all straight in your head? We've got a handy reference sheet showing the differences between Case Management, Care Coordination and Social Support which you might find useful – just pop your details in the box below and we'll send it to you to download.