The term ‘care management’ refers to the assessment process for adults with complex and long term care and support needs.
The Care Management Team provides assessment and support for adults whose health condition requires care and support from professionals, from a number of different agencies. The aim of such specialist provision is to reduce crises, prevent, reduce or delay the onset of further care and support needs, including hospital admission.
An assessment collates information from involved professionals who may include occupational therapists, physiotherapists, community nurses, doctors and speech therapists (see also Assessment).
The assessment will be carried out and coordinated by a social care worker who should also liaise with housing, leisure, employment, voluntary sector services as relevant (see Integration, Cooperation and Partnerships).
The adult, and their carer, should be at the centre of the assessment and their views, wishes and aspirations listened to and incorporated into the process.
Care management enables carers and other family members to continue caring for the adult, as long as they are able.
The following are the principles which underpin care management practice:
The team is responsible for a number of different assessments, including:
Care and support planning reviews will be undertaken on a regular basis, in the adult’s home or placement setting (see Care and Support Planning).
Adults whose care and support needs are within the eligibility criteria under the Care Act 2014 (see Eligibility).
The Care Management Team works with adults with complex care and support needs which are ongoing due to advanced age, physical or learning disability, those in receipt of end of life care (see End of Life Care) and those with other long term conditions. These adults are vulnerable and frail, are at high risk of a deterioration in their physical and / or mental health or social situation, and input from a number of different professionals will be needed in order to provide a clear assessment of their care and support needs.
Adults who do not have eligible care and support needs under the Care Act will be offered advice and information where appropriate (see Information and Advice), or support from the Reablement Service (see Reablement Service).
The Care Management Team also receives referrals for adult safeguarding and for assessment, investigation and management of these cases in line with the local adult safeguarding procedures (see Adult Safeguarding).
In order to avoid delays to adults and carers receiving assessments and / or services, work within the Care Management Team should be managed in a time and outcome focused manner. Work load management and case load management tools should support this.
Key to the success of time focused casework is regular and high quality supervision, which should ensure staff are supported and caseloads managed safely (see also Supervision).
The following timescales apply:
Outputs from the Care Management Team are:
Outcomes from the Care Management Team are:
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