Case Management Foundations

By VeriScorePrep Team · 4 min

Case management coordinates multiple services for clients with complex needs. It is a core social-work function in healthcare, mental health, child welfare, aging, and disability services.

Core functions

• Intake and assessment: gather history, identify needs, risks, strengths, and supports.
• Planning: develop a service plan with the client, goals, and specifics of how each will be met.
• Linking and coordinating: connect the client to services; ensure services actually work together.
• Implementation and monitoring: track progress, attend barriers, adjust.
• Advocacy: challenge barriers to services within systems.
• Evaluation and termination: review outcomes; close or step down.

The plan

A written case management plan lays out:

• Goals (specific, measurable, attainable, relevant, time-bound).
• Services to deliver each goal (who does what, when).
• Review dates.
• Client signature or informed agreement.

Coordination skills

• Communication with multiple providers, sharing with appropriate consents.
• Tracking appointments, referrals, and outcomes.
• Avoiding duplication; eliminating gaps.

Discharge planning

A special case — planning the transition from one service setting to another, with attention to continuity of care, supports at the destination, and follow-up. Discharge planning early (not at the moment of discharge) reduces readmissions and gaps in care.