MindMatters Plus: Effective School Case Management: Strategies

2.6 Strategies of effective school case management

1. Case Identification: Identifying the eligibility of the student for case management process

1.1 Ideally, a health professional and/or the SCM team carries out a preliminary assessment process to determine the perceived needs of the student.
1.2 Using its criteria for offering a student case management processes, the SCM team appraises the student's needs and decides whether or not case management processes are appropriate.
1.3 If case management processes are considered appropriate, a case manager is appointed promptly (see 5.1 below).
1.4 An initial case conference is arranged to which the prospective student and parents/caregivers (if appropriate) and other stakeholders are invited.
1.5 The involvement of parents/caregivers depends on the age and maturity of students – written informed parental consent for the student to participate in the case conference would be necessary in many cases.

2. Referral: Linking the student to a team member who establishes a professional relationship with the student

2.1 The student and his/her parents/caregivers are briefed individually on the nature of the case management process; the roles, rights and responsibilities of all involved; and the procedures for collecting information.
2.2 The case management process and criteria for selecting the student and ending case management are explained individually to the student and his/her parents/caregivers.
2.3 The student is invited to discuss the case management process with the SCM, and encouraged to participate collaboratively in shared planning and decision-making.
2.4 The student or his/her parents/caregivers undertakes and gives written informed consent to participate in the case management process.
2.5 In cases where a student has an intellectual disability, written informed consent needs to be appropriately adjusted according to the student's development and particular needs.
2.6 With the written informed consent of the student or his/her parents/caregivers, appropriate accurate information is collected before and/or after the initial case conference. This includes explaining how the information and records will be securely stored, and right of access to and any arrangements for sharing of this information.
2.7 An invitation to provide important missing personal demographic information and data may occur in the context of the initial case conference.
2.8 Respect for and true understanding of the student is paramount, particularly in terms of values, culture, and language.

3. Assessment: Endeavouring to understand the student's perspective, and identifying and assessing the student's needs

3.1 Assessment is a dynamic, educative, and usually ongoing process of identifying main factors and circumstances (eg. student context, family, school, community, peers etc) that either inhibit or enhance the student's health and wellbeing.
3.2 Assessment is likely to involve collecting and appraising information and data from a variety of sources involving a range of disciplines and agencies.
3.3 The amount and type of information and data collected and shared will depend on the nature and level of student need.
3.4 Assessment improves understanding of the student's needs and is the basis upon which a plan of action can be developed and progress evaluated.
3.5 Assessment is student-centred, where the focus is on the student-in-context, and the student and his/her parents/caregivers are encouraged to participate actively in the process.
3.6 Assessment is comprehensive, focusing upon student strengths, protective resources and risks, the past and present, and including a broad range of student needs in areas such as mental health, education, life-skills, cultural, resilience, social, and family.
3.7 Assessment is embedded in a sound knowledge of child and adolescent development.
3.8 An ecological approach is adopted in understanding the needs of student-incontext.
3.9 Assessment outcomes and student-identified needs are documented and communicated in a language that is understood by the student and all stakeholders.

4. Planning: A collaborative and dynamic process of establishing a coordinated action plan with key stakeholders

4.1 The action plan is outcomes focused and, based on the needs of the student, consists of intended outcomes and associated strategies.
4.2 The action plan includes specific time frames, review dates, a projected date for the transition/closure/completion of case management, the roles and responsibilities of all stakeholders, and a set of criteria/performance indicators to enable an evaluation of the outcomes.
4.3 Planning is individualised, inclusive and collaborative; the student and his/her parents/caregivers are encouraged to identify and prioritise his/her needs, and in partnership with the case manager develop the action plan.
4.4 Planning ensures that student needs are balanced with available quality resources.
4.5 Where it is likely that resources will be needed, an administrator is present at the case management meeting and can offer resources as part of the planning process.
4.6 Planning includes the identification of available quality resources and services to achieve the action plan's outcomes, and where such resources and services are limited or unavailable, contingency strategies (eg. advocating for new resources/services to be developed) to ensure maximum success in meeting the student's needs.
4.7 The student and his/her parents/caregivers are encouraged to participate in the identification of resources and services, and where appropriate, independently access alternative options when there are limitations of choice.
4.8 The action plan is documented in a format that makes sense to the student and his/her parents/caregivers, who are signatories of the plan (see example of a Case Conference Record on pp 52 and 53).
4.9 The case management process and implementation of the action plan are clearly understood by the student and his/her parents/caregivers so that they are informed participants who can contribute confidently to making decisions and achieving the action plan's outcomes.
4.10 The case management process must take into consideration that the student's capacity to understand clearly the case management process and action plan implementation is dependent on his/her developmental age and the nature of his/her needs.

5. Implementation: Executing, coordinating, and monitoring the action plan

5.1 A school-based case manager is designated to a student to ensure that there is a coordinated approach and follow up. This case manager will be designated according to a range of factors such as ability to relate to the student and family, and the level of skills required for the case management process. For example, the case manager could be the student services manager, school counsellor, or school psychologist.
5.2 The SCM team holds regular meetings to review case management actions and case loads, and generally monitor case management processes.
5.3 The designated case manager ensures that the action plan is implemented according to the strategies, time frames, periodic reporting, and stakeholder roles and responsibilities agreed upon.
5.4 The designated case manager's coordination role includes:

identifying the services and resources needed to achieve the action plan's outcomes;
briefing the service provider(s);
referring the student to the service provider(s);
convening case conferences;
monitoring the quality of the services provided and progress towards achieving the outcomes;
adjusting the action plan when necessary;
reporting on the outcomes of the action plan;
consulting and communicating on an ongoing basis with the student, service provider(s), and other stakeholders (eg. family, carers, teachers) about the above processes.

5.5 The designated case manager's role is understood and could involve delegation of support or it could include direct support by, for example:

mentoring the student;
counselling the student;
modelling pro-social behaviour;
educating the student and parent(s)/carer(s) about the nature of the services offered;
accompanying the student to appointments, case conferences etc;
being an advocate for the student (eg. ensuring that the student's views are heard and actioned; lobbying for particular resources).

5.6 The designated case manager ensures that appropriate standards of duty of care are applied in the implementation process.
5.7 The designated case manager maintains a good rapport and communication with the student, and respects the student's legal and human rights, privacy and confidentiality within the bounds of safety and well-being.
5.8 Ideally, case conferences are based on good practices associated with facilitating meetings and group processes such as:

Clarifying the purpose of the meeting;
Checking on participants' understanding of the process and intended outcomes;
Ensuring that all participants have an opportunity to speak;
Encouraging all participants to listen to each other;
Making sure that the student's views have been heard and incorporated in shared decision-making and planning;
Endeavouring to be non-judgemental;
Managing conflict in a constructive way;
Using a Solution-focused approach;
Articulating clear outcomes that all participants understand;
Staying within time schedules;
Maintaining accurate written records.

5.9 A collaborative approach is used when implementing the action plan, involving active interaction, collaborative monitoring and reviewing of progress, mutual problem-solving, and collective strategising between the case manager, student, parent(s)/carer(s), other stakeholders, and all service providers.
5.10 The individualised plans (behavioural and educational) are shared with staff involved with the student (class teachers) and ideas about teaching and learning adjustments are negotiated. In cases where out-of-class issues arise (eg. lunchtimes) a plan for implementation is negotiated and shared with relevant staff.

6. Transition or Closure or Completion: Developing a transition plan to move to minimal or no case management

6.1 A transition plan is identified at the commencement of the case management process and developed in collaboration with the student, service providers, and all stakeholders.
6.2 The transition plan is based on the information gathered at the referral and assessment phases, and is informed by the monitoring and reviewing processes.
6.3 The criteria for completing the case management cycle usually include achievement of the action plan outcomes; compliance with legal requirements; and expiry of time frames.
6.4 Planning for risks and transitions includes the provision of ongoing support that assists the student in developing independence and self-advocacy, and maintaining achievements and personal health and well-being.
6.5 Completing the case management cycle can be an emotional experience for the student and should be handled with sensitivity and empathy.
6.6 The student is aware of his/her right to request re-activation of the case management processes in the future.
6.7 A case management process can be re-activated on request of staff, parents/caregivers, and other stakeholders too.

7. Evaluation: Determining the effectiveness of the case management processes and the action plan

7.1 The aims of evaluation are:

To ascertain the effectiveness of the case management processes in relation to the extent to which the action plan outcomes have been achieved, and thus the student's needs met;
To assess the costs against the benefits attained;
To determine student and parent/caregiver satisfaction;
To appraise the quality of the case management processes provided.

7.2 Evaluation is a necessary formative and summative aspect of evidencebased case management practice.
7.3 Evaluation is a formal extension of the monitoring and reviewing process, and is included in case management from the beginning.
7.4 Evaluation is integral to the case management process by being part of the interactive learning cycle and thus contributing continuously to the ongoing improvement of the quality of the service.
7.5 The student, service providers, and all other stakeholders are an essential contributor to the evaluation process.
7.6 Reporting on the evaluation of the effectiveness of each case management process is an integral part of the school-based system of care. In general, this involves:

the designated case manager reporting to the SCM team;
the school's student services or equivalent structure reporting to the school leaders on the effectiveness of the process and any system needs in relation to gaps in services, support and resourcing needs;
including feedback to student services and the SCM team in relation to commendations, recognition, celebration of success, and recommendations for improving processes.

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