Case managers face the difficult task of coordinating the various service providers and healthcare providers of a number of individual clients, ensuring that the clients' needs are consistently being met and that problems are dealt with quickly and appropriately whenever they arise. They serve as the client's advocate and primary point of contact, and must maintain solid working relationships with their clients and colleagues. Having a good service plan in place for each client can make the case manager's job much easier by organizing relevant information and keeping the case manager focused on individualized client care.
Involve the client (and his family where appropriate) at every stage of the service plan development. Meet with the client to discuss his current situation, needs and goals for treatment. Conduct a thorough assessment of the client's medical and mental health and social history to use while writing the service plan.
Identify the client's needs and address them in order of importance. For instance, it is more important to create a plan for remedying a client's homelessness before moving on to providing for spiritual needs. Or an elderly client's inability to obtain needed medications may be more immediately pressing than his social isolation.
Determine realistic, measurable goals for each problem you've noted. Examples of goals could include maintaining compliance with a medication regimen, attending scheduled therapy sessions, submitting a certain number of job applications per week, enrolling in vocational training, etc.
Collaborate with the client and with other service providers to develop a plan of action for achieving goals. Identify the resources available to the client and create a timeline for when certain activities should be completed. Remember to tailor the plan to the individual client. Methods that may help one client achieve a particular goal may not be effective for another client with a similar problem.
Refer to the written service plan when meeting with clients to check progress and revise the plan as needed to help the client achieve the best possible quality of life.
- "Individualized Service Plans"; Paul Spicer, QMRP; 2005
- Independent Life Resources: Why Do We Use an Individual Service Plan?
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