DFCA3-studyguide3 (1)

CHCCCS004
Assess co-existing needs
STUDY GUIDE
for
CHCCCS004
DIPLOMA OF FINANCIAL COUNSELLING
All Case Histories in this text are presented as examples only

and any comparison which might be made with persons either
living or dead is purely coincidental.
First Edition, September 2017
Copyright ownership: Australian Institute of Professional Counsellors Pty Ltd
ACN 077 738 035
This book is copyright protected under the Berne Convention.

All rights reserved. No reproduction without permission.
Australian Institute of Professional Counsellors

Head Office
47 Baxter St., Fortitude Valley, QLD 4006
This book is protected by copyright and may not be reproduced or copied either in part or in whole
nor used for financial gain without the express approval in writing of the owner (Australian Institute
of Professional Counsellors Pty Ltd ACN 077 738 035) of the copyright.
Contents
Unit Overview ......................................................................................................................................... 4
How to Use This Study Guide ............................................................................................................. 5
Unit Outcomes........................................................................................................................................ 6
Introduction ............................................................................................................................................ 9
Section 1: Identifying a Client’s Co-Existing Needs ....................................................................... 11
Understanding a client’s co-existing needs .................................................................................. 13
Information gathering for assessment.......................................................................................... 17
Analysing and assessing client information ................................................................................. 22
Section 2: Determining Appropriate Services .................................................................................. 27
Matching services to client needs.................................................................................................. 28
Providing information and assistance .......................................................................................... 30
Documenting the case management plan and making referrals ............................................... 32
Section 3 Evaluating Assessment and Referral Processes .............................................................. 35
Evaluating Assessment and Referral Processes .......................................................................... 36
Monitoring assessment and referral processes ............................................................................ 36
Collecting client feedback on your own service provision ........................................................ 40
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Unit Overview
Unit Overview
Unit Title
CHCCCS004 – Asses co-existing needs
Unit Purpose
This unit describes the skills and knowledge required to assess the diverse and multi-faceted
needs of people and determine both internal and external services required to meet those needs.
Prerequisites
This unit has no pre-requisites.
Content
▪ Identifying a Client’s Co-Existing Needs
▪ Determining Appropriate Services
▪ Evaluating Assessment and Referral Processes
Resources/Readings
Readings A – H are located in the associated Book of Readings.
Suggested Hours
Although everyone will work at their own pace, we suggest you allow approximately 80 hours
to complete this unit competently, including seminars, tutorials, assignments and any practical
activities.
Time Frame
The recommended time frame for this unit is no more than 4 weeks.
Assessment
This unit will be assessed by completing the CHCCCS004 Assessment Book and an associated
practical assessment.
Please submit your Assessment Book via your online student portal at http://my.aipc.net.au
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How to Use This Study Guide
How to Use This Study Guide

This Study Guide and associated Book of Readings contain all of the information that you need
to complete the assessment tasks associated with this unit. You must read through all of the
information provided (both the Study Guide and associated Readings) before attempting the
assessment tasks.
Throughout this Study Guide there are a few icons used to help you. These include:
The Tip Icon

This is used to indicate the presence of tips or additional instructions that
may assist you as you work through this Study Guide. You will usually find
them at the beginning of each Section of the Study Guide to indicate which
Readings supplement the information provided in that Section.
The Reading Icon

You will find these throughout the Study Guide. They indicate that a
particular Reading contains additional information on the topic that is being
discussed at that point.
Reading A
The Reflect Icon

This indicates a self-reflection question. You are not required to submit
answers to these questions. They are designed to get you thinking more
about the topic and to consider key points in order to aid your
understanding.
Thank you for choosing to study with The Australian Institute of Professional Counsellors. Best
Wishes!
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Unit Outcomes
Unit Outcomes
Upon completion of this unit, you should be able to:
Element Performance Criteria
1. Prepare for assessment 1.1 Identify and prepare assessment tools and processes
according to organisation policy and procedures
1.2 Gather existing information about the person
1.3 Seek additional information from specialists and
other sources as required to determine the range of
issues that may be affecting the person
1.4 Organise practical aspects of assessment in
consultation with the person being assessed
1.5 Provide information about the assessment process to
the person and obtain consent
2. Analyse the person’s needs 2.1 Work within scope of own role and seek assistance
using a collaborative approach from colleagues and experts as required
2.2 Empower the person to identify and prioritise their
own needs
2.3 Evaluate needs based on full range of relevant
information
2.4 Identify and analyse complex, multiple and
interrelated issues
2.5 Evaluate issues of urgency and eligibility
2.6 Assess potential risk factors for service delivery
3. Determine appropriate 3.1 Consider service delivery and referral options from
services strengths-based perspective
3.2 Evaluate internal capability and other service
networks to determine best fit for the person
3.3 Provide the person with service information and
support their decision making process
3.4 Encourage the person to advocate on their own
behalf to access services
4. Complete reporting 4.1 Document the outcomes of the assessment process

according to organisation procedures
4.2 Maintain and store the person’s information
according to confidentiality requirements
4.3 Provide the person’s information to other services
according to consent and confidentiality
requirements
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Unit Outcomes
5. Evaluate assessment and 5.1 Seek feedback about assessment processes from the
referral processes person and other networks
5.2 Monitor processes and their outcomes in terms of
success in meeting the person’s needs
5.3 Routinely seek feedback and reflect on own
performance
5.4 Use feedback and own evaluation as a basis for
improving processes
KNOWLEDGE EVIDENCE
The candidate must be able to demonstrate essential knowledge required to effectively complete
tasks outlined in elements and performance criteria of this unit, manage tasks and manage
contingencies in the context of the work role. This includes knowledge of:
▪ different types of assessment and their use in different contexts
▪ assessment process:
- roles and responsibilities of different people
- impact of the setting on the process
- roles and types of assessment tools
- ways of collecting information
- validity and reliability requirements
- reporting requirements and formats
▪ nature and impact of diverse and multi-faceted needs and issues affecting client groups,
and potential interrelationships between them, including:
- mental health
- alcohol and other drugs
- imprisonment
- child protection
- family violence
- homelessness
- poverty
- health
- age
- disability
- behaviours of concern
- employment
- culture and religion
▪ common service requirements and basic features of those services including:
- employment
- physical and mental health
- housing
- community support
- social inclusion
- education and training
- financial support
▪ networks and specialist services available
▪ legal and ethical considerations relating to assessment processes, including:
- privacy, confidentiality and disclosure
- duty of care
- informed consent
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Unit Outcomes
PERFORMANCE EVIDENCE
The candidate must show evidence of the ability to complete tasks outlined in elements and
performance criteria of this unit, manage tasks and manage contingencies in the context of the
job role. There must be evidence that the candidate has:
▪ assessed and appropriately responded to the requirements of at least 3 people presenting
with co-existing needs
▪ used analytical and critical thinking skills in each case:
- applying a strengths-based approach to assessment
- analysing information about co-existing issues
- making evidence-based judgements about the person’s needs
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INTRODUCTION
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Introduction
Introduction
About this Unit:
This unit describes the skills and knowledge required to assess the requirements of clients with
diverse and multi-faceted needs and provide appropriate referral to both internal and external
sources of support.
Overview of Sections:
Section 1: Identifying a Client’s Co-Existing Needs
In this section of the Study Guide you will be introduced to some of the key issues surrounding
working with clients with co-existing needs. You will also learn how to determine and analyse a
client’s needs (including their urgency, complexity, and risk) using a collaborative approach.
Section 2: Determining Appropriate Services

In this section of the Study Guide you will learn how to determine appropriate services to
support client needs. You will learn about the processes involved in understanding available
services and matching services to client needs. You will also learn more about the importance
of promoting client independence and encouraging client self-advocacy when accessing services.
Section 3: Evaluating Assessment and Referral Processes

In this final section of the Study Guide you will learn more about evaluating assessment and
referral processes. You will learn how case managers go about seeking feedback about the
assessment process from both the client and other service providers and how they go about
monitoring service provision and using this information to evaluate and improve upon their
own practices.
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Section 1
IDENTIFYING A CLIENT’S
CO-EXISTING NEEDS
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Identifying a Client’s Co-Existing Needs

About this Section:
In this section you will learn how to:
− Gather information about clients
− Prepare, conduct, and document assessment processes according to organisational
policies and procedures
− Seek additional information from specialists and other sources as required to determine
the range of issues that may be affecting a client
− Empower a client to identify and prioritise their own needs and evaluate needs based
on full range of relevant information
− Evaluate issues of urgency and eligibility
− Assess potential risk factors for service delivery
− Document the outcomes of the assessment process according to organisation
procedures
− Maintain and store a client’s information according to confidentiality requirements
Supporting materials:
The following materials supplement the information provided in this section:
1. Reading A
2. Reading B
3. Reading C
4. Reading D
In the previous unit of your Diploma, CHCCSM005 Develop, facilitate and review all aspects of case
management, you were introduced to the core processes and techniques of case management,
which underpins much of community services work (including the work of financial
counsellors). The aim of this Study Guide is to build upon this foundation and introduce you
to the skills and knowledge required to assess and support the needs of clients with co-existing
needs (i.e., clients with multiple needs) because, although the overall case management process
remains the same, there are additional considerations involved in working with clients with co-
existing needs that case managers (and financial counsellors working in a case management
context) must be aware of.
A note on terminology: As you learn about clients with co-existing needs, you will learn that
there are often a number of different terms used to refer to such clients. You might see the
terms “complex clients” and “dual diagnosis clients” in some of the literature. However, there
has been a shift away from using such terms in recent years. For example, many practitioners
do not believe the term “complex clients” is appropriate because that word has negative
connotations and may suggest that the client is difficult. Similarly, the term “dual diagnosis”
implies that a client has two diagnoses which define them, when in reality people and their needs
are much more complicated. Additionally, this term does not account for a client’s often
Reading A interrelated social needs, such as housing issues or unemployment. Reading A provides a brief
introduction into some of the issues surrounding co-existing issues for people from the mental
health/substance use field and discusses some of the problems surrounding use of terminology.
The term ‘co-existing’ needs is currently preferred because it recognises that clients have a
number of interrelated issues that need to be identified, assessed, and incorporated into the
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client’s case management plan. Remember, when working with clients with co-existing needs it
is important to keep in mind that an individual’s needs should not be viewed in isolation because
clients do not generally experience isolated problems, instead, there is a complex interaction
between an individual’s various needs (NADA, 2013).
Clients with co-existing needs make up a significant proportion of clients in the community and
human services sector. Unfortunately, these clients are often the most likely to “fall through the
gaps” of services, as reported in the seminal paper by Rankin and Regan (2004). Reading B was
taken from this paper and highlights the importance of having a thorough understanding of co-
existing needs, as well as outlining some of the client groups who are more likely to fall through
the gaps of service provision. All workers in the community services sector (including case
Reading B managers and financial counsellors) need to be vigilant to ensure that all clients are adequately
assessed and supported. To be able to do this, it is important to first understand the nature of
co-existing needs.
So, what are co-existing needs? Needs can be thought of as the gap in the client’s life between
their current situation and their desired situation. For example, a person who is homeless has a
need for housing, so addressing their need would involve finding them emergency shelter and
then supporting them to find more stable accommodation. But what if the person is homeless,
has a mental illness, and abuses substances as a result of a traumatic childhood? This is where
the situation starts to get more complex as the client has multiple and intersecting issues that
are dictating their needs – these are co-existing needs and in this situation the case manager’s
role is more complicated because they must consider which needs to address first and how to
best address the interaction of these needs.
Understanding a client’s co-existing needs

In order to develop an effective case management plan with a client, case managers need to
develop a comprehensive understanding of the client’s full range of needs. We will explore how
case managers can go about gathering this information in collaboration with the client later in
this section of the Study Guide; for now, let’s review what information case managers are
typically interested in.
You have previously learned about the importance of case managers conducting a holistic
assessment of each client and analysing the relationship between the client’s social,
psychological, physiological, and economic circumstance. This is particularly important when
working with clients with serious co-existing needs. Additionally, co-existing needs impact upon,
and are influenced by, multiple areas of a client’s life. As such, when gathering information, case
managers need to consider all aspects of a client’s life – past and present. By adopting a holistic
approach to information gathering, case managers can ensure they are developing the most
complete picture of the client and their needs and, consequently, will be able to most effectively
address their needs.
Case managers are particularly interested in developing an understanding of the most important
issues, needs, and concerns that bring clients into contact with services and impact service
provision. These include:
▪ Poverty
Poverty can have a detrimental effect on a person’s ability to participate in activities that
most people take for granted. The following extract is taken from the Salvation Army’s
report on poverty in Australia and helps to provide some understanding of the effect
that coming from, or living in poverty may have on a client’s life:
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“The World Bank states that ‘Poverty is hunger. Poverty is lack of shelter. Poverty is
being sick and not being able to see a doctor. Poverty is not having access to school
and not knowing how to read. Poverty is not having a job, is fear for the future, living
one day at a time. Poverty is losing a child to illness brought about by unclean water.
Poverty is powerlessness, lack of representation and freedom.’
The Salvation Army knows from experience that there are people in Australia who fit
this description of poverty. People who can’t find a job, people who are not able to
get the medical attention they need, people who have lost hope and live one day at a
time.”
(Gallet, 2010, p.10)
▪ Health concerns
Physical health concerns can affect multiple aspects of a person’s life. Poor physical
health can lead to additional financial stress as clients may need to purchase medications
and visit specialists. Poor health can also cause emotional stress and the possibility of
social isolation.
▪ Mental health
Mental health concerns are quite common, with one in five Australians experiencing
some form of mental illness every year and 45% of Australians experiencing a mental
illness at some stage of their life. In Australia, mental disorders are the third leading
cause of disability burden with major depression accounting for more days lost to illness
than almost any other physical or mental disorder (Mindframe, 2014). Additionally,
mental disorders are often found to co-exist with substance misuse issues. It is difficult
to ascertain true rates of co-existing issues such as substance misuse and mental illness
as mental health and alcohol and other drug services are not sufficiently integrated.
“There is extensive consensus across the literature that people with comorbid substance
misuse and mental illness face challenges compounded across several domains. The
complexities of negotiating everyday life, as well as treatment and service engagement
between agencies and across sectors can be quite complex.” (Graham & White, 2011, p.
4).
▪ Alcohol and other drugs
As previously mentioned, concerns with alcohol and other drugs often co-occur with
other issues, such as mental health issues. Drug use is often both a symptom and a cause
of problems in people’s lives. People who abuse and/or are addicted to drugs often have
a history of trauma. Within the general Australian population, drug use is considered a
concern with alcohol fuelled violence often being reported in the general media. “In
2013, just over 40% of Australians either smoked daily, drank alcohol in ways that put
them at risk of harm or used an illicit drug in the previous 12 months; 3.1% engaged in
all 3 of these behaviours” (AIHW, 2014).
▪ Disability
Having a disability can have a significant impact on multiple areas of a person’s life.
Depending on the type of disability a person may have, this can affect their ability to
work, participate in education or training, travel, or even care for themselves. In some
cases, people with disabilities can be marginalised from full participation in society and,
as a result, feel socially isolated.
▪ Employment
Being unemployed has an obvious impact upon an individual’s standard of living but
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can also negatively impact a person’s mental health and wellbeing, and have a flow-on
effect to the person’s family and community. People who are out of work for six months
or more tend to be in poorer health and have children who are performing worse
academically compared to similar people who are employed (Nichols, Mitchell &
Lindner, 2013). This highlights the effect that unemployment can have on the
unemployed person and their family as well.
▪ Imprisonment
Many people who have had experience with the criminal justice system have a history
of disadvantage, trauma, mental health issues, and drug and alcohol use. Mental illness
and impairment are diagnosed at a much higher rate in prison populations than in the
general population. Additionally, being incarcerated can have many ongoing, negative
effects on a person’s life, including diminishing their sense of self-esteem and self-worth,
and their ability to find employment.
▪ Child protection
Children and families are involved in the child protection system when it is assessed that
a child is likely to experience, or has experienced harm and they do not have a parent
who is willing or able to protect them. The most common reasons for involvement with
child protection include family violence, parental drug misuse, and parental mental
health concerns. Involvement with child protection can be an incredibly stressful
experience for families, as most families are concerned that their children will be
removed, although this is the least likely course of action for the majority of families.
Furthermore, when families become involved with child protection they are often at
crisis point. In addition to the issues that cause a family to become involved with the
child protection system, many parents also experience a sense of shame and failure as a
result of the situation.
▪ Family violence
Family violence refers to abuse that is suffered within a family, most often at the hands
of a male partner towards a female partner. However, abuse can also occur between any
members of the family, such as a female partner towards a male partner, within
homosexual relationships, between siblings or inter-generational violence. Family
violence does not only refer to physical violence, but can include emotional, social,
financial, psychological and sexual controlling and manipulation behaviours.
▪ Homelessness
Every night in Australia, more than 100,000 people are homeless. Homelessness not
only involves people who are sleeping rough on the streets, but also includes people
who are staying in crisis accommodation, or who are couch surfing, or staying in severely
overcrowded accommodation that would not meet a minimum standard of living in
Australia. There are many causes of homelessness, such as family violence or
breakdown, substance misuse issues, mental health problems or financial difficulties.
The majority of homeless people are young people and children who are part of a family
group, such as a single mother, who is fleeing domestic violence with her children.
Homelessness can have a significant emotional and social impact on an individual, and
although housing is always a top priority, it is important to also consider why a person
became homeless and address these causes to prevent an individual becoming homeless
again.
▪ Behaviours of concern
Behaviours of concern (also sometimes referred to as challenging behaviours) is a very
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broad description that describes behaviours that have the potential to result in an
individual harming themselves, others, or causing damage to property. Some examples
of behaviours of concern include self-harming, acts of violence or aggression towards
others, acts that cause damage to property, and refusing medication. It is important for
case managers to be aware of behaviours of concern because these should be addressed
in the case management plan and may need to be considered when making referrals
(some organisations may not be equipped to appropriately manage such behaviours).
▪ Age
The age of a client can be an important consideration when completing an assessment
of a client’s needs. Their age may have an effect on the sorts of activities they can
participate in and their interests. For younger clients, you may need to seek parental
permission for referrals. For older clients, they may have issues with mobility or
cognition, so it is important to ensure that any referrals are age appropriate.
▪ Culture and religion

When gathering information about a client, it is crucial to consider their cultural and
religious needs. Australia is a very diverse country with many different religious and
cultural groups. It is important to gather religious and cultural information from the
client to ensure their needs are being met.
As you can see, these issues can all have an impact upon a client’s situation and, in the case of
co-existing needs, a number of these factors can be interrelated and increase the complexity of
working with the client. In some cases, failure to receive adequate support in the past has, in
turn, compounded the client’s ability to access support and treatment, which has then
exacerbated their issues – creating a cycle of disadvantage that is difficult to escape, as depicted
in the figure below.
Source: NADA, 2013
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Case managers must develop an awareness of the full range of issues that may be having an
effect on a client. For example, when working in the homelessness sector, the case manager
should not just consider the client’s need for accommodation, but should consider and address
factors that may have contributed to the client’s homelessness (e.g., they may also be
experiencing issues with mental health, substance misuse, or be fleeing family breakdown or
violence). Clients who experience serious, multiple disadvantages will find several (if not all)
areas of their life are affected and can, in turn, have difficulty meeting the needs of themselves
and their families. The following case study highlights the interplay between several factors.
Case Study
As a child, Margrethe was subject to childhood abuse at the hand of her mother’s partner.
Throughout her life, Margrethe battled with depression as a result of her childhood trauma
but managed to maintain employment and stable housing. When Margrethe was 25 years old,
she experienced the death of her mother and became severely depressed. Although Margrethe
had previously used drugs recreationally, she started escalating her drug use to cope with her
depression and subsequently became addicted to heroin. Due to her addiction and the
dysfunction that followed, she lost her job and subsequently her accommodation and all social
supports. Now 31 years old, Margrethe is homeless and registered as disabled as result of her
substance abuse problem.
When working with a client like Margrethe, it is important to consider all of the factors that
led to Margrethe’s current situation in order to be able to comprehensively address her current
issues. For example, simply helping Margrethe access affordable housing is unlikely to lead to
long-term success because her depression and drug addiction are likely to impact upon her
ability to retain the housing. Margrethe has several issues impacting on her life and her case
manager would need to consider the ‘big picture’ when it comes to addressing Margrethe’s
issues.
Essentially, case managers need to ensure that all relevant information about the client is
gathered before forming an assessment of the client’s needs. So how do case managers go about
gathering this information?
Information gathering for assessment

The central goal of the assessment process is to gather and assess the client’s information in
order to determine their needs and requirements. In many cases, clients with co-existing needs
will have been involved with several services throughout their lives – in such cases it is important
to also gather information regarding this to get an idea for what has or hasn’t worked for a client
in the past. Collecting information from a wide variety of sources will allow for a more detailed
picture of the client’s needs to be formed. When conducting an assessment, case managers will
typically seek out information from some combination of the following sources:
▪ The client. You should be clearly aware by this point in your studies that case
management is a collaborative process in which the case manager works with the client
to help understand and meet the client’s needs. As such, the client themselves should
be the central source of information during the assessment process.
▪ The client’s, family, significant others, and carers. When working with people with
co-existing needs, it is usually useful to adopt a holistic, whole of family approach.
Clients with co-existing needs will often have difficulties that are chronic, inter-related,
and often inter-generational (Bromfield, Sutherland & Parker, 2012). Taking the time to
get to know and observe the client and their family can help develop a more intricate
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picture of the client’s needs. Of course the client should be the focus, and the client is
often the best source of information to inform the case manager about what they need.
Remember, an assessment should be completed with a client and not conducted on a
client. The process of assessment itself can often be helpful for clients and their families
as it can help them put their situation into context and examine the effect of past
incidences on current circumstances.
▪ Existing case documentation (e.g., referral forms, intake documents, existing

case notes, etc.). Case managers should also consider information that they can gather
from existing case documentation. Referral documents and intake documents are often
quite detailed and provide an overall picture of the client and their needs. Additionally,
in some cases (particularly when working with clients with multiple or co-existing needs)
the client might have had prior contact with the current organisation or other
organisations and the client’s case files can hold a vast amount of information about the
client’s previous contacts, assessment results, case plans, progress and outcomes. This
information can help the case manager better understand the client’s needs in a broader,
holistic context, however, it is still important for the case manager to conduct their own
assessment of the client’s current needs and circumstances.
▪ Other professionals/specialists. Case managers might seek out information from

other professionals and specialists, particularly if they are unsure about a particular
aspect of the client’s needs. For example, if the referral or case documentation note that
the client has a particular physical or mental health diagnosis that the case manager is
unfamiliar with, it would be appropriate to discuss what impacts this diagnosis should
have on the case management plan with a suitably qualified professional. In most cases,
it is best to obtain the client’s consent to discuss the client’s case with the professional
they have been working with.
▪ Assessment tools. Throughout the assessment process case managers can use a
number of different assessment tools. The type of assessment that a case manager may
use will depend on the purpose of the assessment as well as the organisation’s standard
practices for collecting and assessing clients. For example, a case manager who works
with clients of domestic violence may be required to do a risk assessment as a priority
to ascertain the client’s safety before moving onto assessing the client’s needs. Whereas,
an assessment completed with a youth justice client may involve an assessment that
focuses on addressing offending behaviour. Additionally, case managers will use their
professional judgement to decide what assessments to use, and how to approach
working with a client. This involves considering the individual needs of the client and
the practical considerations required. For example, a young Muslim girl may require a
translator to speak with the case manager, and the only translator available is a man.
Therefore, the case manager may assess that it would not be appropriate to gather
information on the young person’s physical health, as it may not be appropriate for her
to speak about such things in the presence of a man. The case manager will have to
consider the individual situation with the client, the purpose of the assessment, the
practical considerations and their organisation’s policies and procedures regarding
assessment when deciding what type of assessment to utilise.
In general, there are five basic types of assessment tools. These are:
1. Screening assessments: the purpose of screening assessments is to gather information
about a client in order to confirm their eligibility for service provision. These
usually involve the use of a questionnaire or intake interview.
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2. Domain based assessment: the purpose of a domain based assessment is to understand

how a particular area, or domain, impacts on a person’s life or how they are
functioning in a particular domain. For example, assessing a person’s drug use,
their daily functioning, level of disability, etc.
3. Norm based assessment: the purpose of norm-based assessment would be to compare
the results obtained from the client against their peers. For example, a child’s
development may be assessed to see if they are developing at a normal rate
compared with other children.
4. Competency based assessment: the purpose of competency based assessment is to
assess whether a client is competent in a particular area. For example, a client with
a disability may be assessed on their independent living skills.
5. Diagnostic assessments: the purpose of diagnostic assessments is to determine if the
client has a particular diagnosable condition. Generally case managers will not be
expected to administer diagnostic assessments unless they have additional specific
training. Typically, diagnostic assessments are completed by other professionals
(e.g., psychologists).
The ultimate purpose of assessment tools is to help the case manager understand the
client’s needs so that they can work with the client to develop an appropriate case
management plan. When using assessments it is important to ensure that they are valid
and reliable. A valid assessment is one that accurately measures what it is supposed to
measure, and a reliable assessment is one that gets consistent results from the client if
they take it more than once. In order to help ensure validity and reliability, case managers
must ensure that they follow any standardised instructions and procedures when
conducting assessments.
When gathering information and conducting an assessment there are a number of additional
considerations that case managers should keep in mind. Firstly, it is important for the case
manager to be mindful of the client’s comfort and prepare them for the information gathering
and assessment process. This process usually requires the case manager to gather a range of
detailed information about the client. Without beginning by explaining to the client why this
information is needed and what the case manager will be doing with it clients can be very
reluctant to discuss their details. It is always important for case managers to clearly explain the
assessment process to the client. Let’s have a look at an example of how that can be done.
Case Study
Angela is a case manager for a disability support organisation. As a part of her job she meets
with the new clients to assess their needs in order to understand how the organisation can
best assist the client. Today Angela is meeting a client, Fiona. Fiona lives at home and is
requiring an assessment to determine what she needs to assist her in her daily life. When
Angela meets with Fiona she explains how the process will work:
“Hi Fiona. Firstly, I wanted to speak with you about what we will be doing here today and
what will happen afterward. So today I will be doing what is called a ‘Needs Assessment’. I
will ask you questions about yourself, your job, your home and what you would like for the
future. This will take about two hours to complete. Some of these questions may be quite
personal, so if you are feeling uncomfortable at any time, please let me know. Once the
assessment is complete, I will be able to work with you so that we can determine the best
support services to assist you. We will arrange another appointment next week to discuss your
options. How does that sound? Do you have any questions for me?”
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Additionally, in some cases, clients with co-existing needs can be difficult to engage as they can
be resistant to engagement due to past experiences in which services have proven to be
unhelpful. Some clients may have also been excluded from services because their needs were
deemed ‘too complex’ (for example, a mental health service may not accept people with
concurrent drug abuse issues). Alternately, a client may have been involved with a variety of
services over the course of their life who have operated in isolation from each other, chipping
away at the client’s problems from a number of different angles but ultimately leaving the client
frustrated. Therefore, building trust and rapport, although an essential skill for any case
manager, becomes a crucial skill when working with clients with co-existing needs. Building a
relationship with the client has been found to be the most important determinant of positive
outcomes for clients with co-existing needs because it enables the case manager to gather all
relevant information about the client and allows the client to more effectively engage with the
case management process (Bromfield, Sutherland & Parker, 2012). While you have already
developed an understanding of a number of rapport building skills throughout your Diploma,
Reading C outlines some of the specific strategies employed by the Victorian Department of
Human Services when engaging with and gathering information from families with multiple and
Reading C interrelated needs – this Reading provides a good overview of rapport building in the context
of working with families with multiple and co-existing needs, as well as outlining some of the
barriers of working with clients with co-existing needs.
When conducting assessments case managers also need to ensure that they consider the practical
components of the information gathering and assessment process. This may include:
▪ The physical environment: It is important to consider the impact that the physical
environment will have on a client, particularly if they are talking about sensitive issues.
For example, some clients may find the office environment intimidating, so scheduling
a meeting in an interview room may not be appropriate. Of course, it is also important
to consider privacy and confidentiality issues when arranging for assessment at the
client’s home. Ultimately, the client must be comfortable with the location of the
assessment but case managers must ensure that they comply with all organisational
policies and procedures.
▪ People present during the assessment: Prior to beginning the assessment process,
the case manager should outline what will be involved and enquire if other people will
need to be involved in the assessment. For example, would the client feel more
comfortable with a support person present? Is an interpreter required for the
assessment?
▪ Time of day: Just as when you book an appointment with the doctor you try to find a
time that suits their opening hours and your schedule. The same would apply for case
management clients. For example if you are working with a mother, would it be better
to schedule the meeting during school hours? Some clients may be more alert in the
morning or the evening due to a particular condition. It is best to gather the preference
from the client.
▪ Individual needs: It is important to discover any details that might put the client at
ease during the assessment. For example, does the client smoke? If so, will they need
regular smoking breaks? Are there any other individual needs that will need to be
catered for?
It is important to discuss these sorts of details with your client and determine their preferences.
Ultimately, the case manager must have the informed consent of the client in order to engage
in the assessment processes. This is a legal and ethical requirement. Case managers need to
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ensure they obtain their client’s permission to work with them to collect and assess their
information, and this involves adequately explaining the reason for the assessment, what
information will be collected, and why. If a component of the assessment needs to be conducted
by another professional (e.g., mental health concerns assessed by a psychologist) then this
should also be explained. It is important to inform the client of all the people who may be
involved in their assessment. Most organisations will also require the client to sign a consent
form to document this process. As you may recall from previous Study Guides, it is important
to remember that the client’s information is protected by the Privacy Act 1988 and as such, the
client’s privacy and confidentiality needs to be protected. Case managers must obtain a client’s
permission to gather personal information and outline any situations in which this information
would be released. It is also important to seek the client’s permission to store their information
securely, according to organisational policy. Additionally, case managers must ensure that they
seek their client’s consent before they disclose their information with other organisations, such
as for referrals.
Another legal and ethical requirement that case managers must keep in mind that can relate to
assessment processes is duty of care. Case managers have a responsibility to act to reduce or
limit the amount of harm a client may experience through the case manager’s actions or
inactions. In some cases, the assessment process and the organisation’s standard assessment
tools could be problematic or triggering for a client. If the case manager has any concerns about
the manner in which the assessment process will be conducted they should discuss the matter
with their supervisor. However, in the absence of such concerns (and subsequent discussion
with a supervisor), it is important for case managers to conduct the assessment process in line
with all organisational policies and procedures.
A note on documentation
The approach to information gathering and assessment will vary according to organisational
processes and procedures. For example, some organisations rely heavily on standardised
screening questionnaires followed by domain assessments, whereas other organisations may
simply use a general intake conversation as the basis of assessment. Regardless of the approach
used, it is important for case managers to document all information gathered according to their
organisation’s relevant policies and procedures. In the case of any standardised assessments, the
case manager would need to follow the recording procedures for that assessment. In the case
of general intake conversations, these may be recorded in case files and then written up for
formally as an assessment report.
It is best practice to formally write up the information you find out during an assessment. An
assessment report is basically a summary of the key bits of information gathered in an
assessment process. It is a useful document kept on the client’s file so that other workers and
new staff can refer to it when working with the client. It can also be shared with other services
if the client gives consent. This reduces the need for the client to repeat their story to other
support workers.
(Johnson & Keegan, 2012, p. 60)
As previously mentioned, most organisations will have specific procedures related to assessment
and the storage of client information – it is vital for case managers to follow such procedures
and ensure that all information is stored in accordance with organisational confidentiality
requirements.
Once all relevant information about the client has been gathered, the case manager can begin
21
the process of analysing and assessing these needs and developing the case management plan in
conjunction with the client.
Analysing and assessing client information

Assessing and analysing client information is not a linear process, however case managers need
to ensure that no premature decisions are made until all relevant information has been collected.
This is especially true for clients with co-existing needs as it would be very easy to make quick
judgements and assumptions based on the wealth of prior information likely to already exist in
referrals and case notes. Case managers have equated information gathering as collecting puzzle
pieces and the process of assessing the information as like fitting the puzzle pieces together to
see the big picture (Woodside & McClam, 2013).
Hence, the assessor’s role can be likened to a detective, looking for clues and developing
hypotheses about the client and the system around them. The search for information is not
exhaustive and unlimited, but remains focused by the question, “What do we need to know
about this client, and the services around them, at this time?” As an assessor becomes more
skilled, and with supervisory and collegial support, they learn that it is not always necessary
to know everything about an individual to develop an effective model of care. The key is in
sifting through the sometimes vast amount of information to identify what is important to
know.
(WRHC, 2013, p. 11)
Analysing client information in order to determine service requirements often involves a

collaborative approach, particularly with clients with co-existing issues who usually require
support from a variety of service providers. Although case managers may work in a specific
field, people and their issues are variable and clients are likely to have needs outside the scope
of the case manager’s expertise. So it is important that a case manager seeks assistance from
colleagues and experts as required when reviewing a client’s needs to ensure that all client needs
are addressed. For example, a case manager who supports clients with housing issues may
encounter a client who appears to have substance misuse issues or mental health issues. It would
be imperative for the case manager to develop plans around these issues. Failure to adequately
support a client’s co-existing needs could lead them to falling through the gaps of service
provision.
Reading D provides a good overview of the process that one organisation uses to collect and
assess client information for the purposes of determining appropriate services. This Reading
comes from the Indigo program, which is a specialist program developed as part of the Victorian
Multiple and Complex Needs Initiative. The initiative was created in recognition that clients
Reading D with multiple and co-existing needs often fall through the gaps of social services and need
targeted and specialist care plans. Although Indigo is a specialist program, the methods
described in the reading provide valuable information regarding gathering information and
assessing any clients with co-existing needs. The extract below describes an important
component of assessing client information, which is seeing the whole person in context.
External stakeholders have noted that Indigo assessments describe the client’s needs and
story in a way that humanises, demystifies and de-stigmatises them. Indigo assessments ideally
place a person in context, broadening the narrative to highlight the social and structural
factors that lead an individual to where they are today.
(WRHC, 2013, p. 17)
22
It is also crucial to work from a strengths based approach when working with clients with co-
existing needs. This involves seeing the person as a whole and understanding and utilising their
existing strengths and resources. When case managers work with clients from a strength based
perspective and examine their issues in a holistic manner, clients are also able to see their issues
and strengths more clearly. This process can be empowering for clients, as self-awareness and
understanding your own needs is the first step to being able to advocate for yourself (which is
still a focus of case management for clients with co-existing needs)
When analysing and assessing client needs, there are a few key factors that case managers should
keep in mind. We will review these now.
Urgency of issues
One of the first steps in the planning process, particularly when working with clients with co-
existing needs, involves helping the client to prioritise their needs in order of urgency. Some
organisations will have an established priority scale or similar tool that has been designed to
prioritise the urgency of the client’s needs. Typically this is similar to a risk based assessment
and it would include the likeliness of a factor occurring measured against the consequence of
an event happening. This can then help case managers work with the client to determine
priorities – with the highest priority going to any factors that have serious consequences and a
high likelihood of happening. This makes logical sense and similar approaches are used in other
domains. For example, when learning first aid you are taught to assess patients via an order of
priority – Danger, Response, Airway, Breathing and then Circulation. There is no point applying
a band-aid if the person cannot breathe!
Another commonly used tool to help prioritise needs is Maslow’s Hierarchy of Needs (see
diagram below). Maslow’s Hierarchy works on the principle that physiological needs are a
person’s highest priority because these needs impact the ability of a person to survive from day-
to-day. From there, the next priority are needs related to safety. After that are needs related to
belonging, esteem, and self-actualisation (in order of priority). For example, by using Maslow’s
Hierarchy, a case manager would assess a homeless client’s need for accommodation as higher
than their need for social interaction. This process can help ensure that the client’s needs are
prioritised in an appropriate order.
(Bromfield, Lamont, Parker & Horsfall, 2010)
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While prioritisation seems like a simple process, the issue that often stumps beginner case
managers is what to do when the client’s own assessment of priority differs to their own.
Because the client is central to the assessment and planning process, the client’s own concerns
should be given priority – indeed, the client’s likelihood of participating effectively in the case
management plan is highest when the plan is addressing the needs they are most interested in.
However, that is not to say that the case manager cannot discuss their perspectives with the
client, particularly in cases in which the client’s safety is in jeopardy. Remember, case managers
have a duty of care to their clients.
In general, the order of priority should include:

1. Needs that are a threat to the client’s immediate safety
2. Needs that the client prioritises
3. Needs that the case manager highlights (however, if the client is not interested in
addressing these needs the case manager should simply monitor these needs until the
client wants to work on them).
4. Potential needs that the client may have in the future but which are not impacting them
currently.
By prioritising needs, the case manager begins to develop a fuller picture of the client’s service
provision requirements. From there, the case manager can begin working with the client to
develop specific goals and develop the case plan.
Client eligibility for services/supports

An important component of the assessment process is determining whether a client meets the
criteria for entry into a program or service that the case manager believes may assist them. As
many community services programs are government funded, they may require clients to meet
certain criteria to be able to participate in the program. Case managers need to ensure they are
only making legitimate and helpful referrals to other services. As such, case managers should
ensure that they gather all relevant eligibility information from the client.
The complexity of client needs

A client’s needs cannot be viewed in isolation – clients with co-existing needs may have multiple
needs that may impact on one another. As such, it is important to take a holistic view of the
client and consider how their needs might interrelate. The client’s situation should be viewed as
a whole and addressing each client’s needs will usually take a whole of service approach. This
means that all professionals should work together as a team to address client needs.
However, case managers need to be careful when trying to address too many needs at the same
time because, when not done appropriately, the client can become overwhelmed and fail to
accomplish anything. For example, referring the client to a service to address each of their
needs/issues at the same time can become too much for the client to deal with. Although clients
with co-existing needs do require a multi-service approach, it is important not to involve too
many professionals simultaneously in the client’s life. Rather, the case manager should stagger
the various interventions within the client’s case management plan (the urgency of each need
would inform which needs are addressed before others). Alternately, the case manager may
specifically search for organisations/professionals that can address multiple client needs at once.
Risk management
Clients with co-existing needs may have a variety of risk concerns, including:
▪ Severe mental health concerns
24
▪ Offending behaviour
▪ Substance misuse issues
▪ The possibility of crisis situations
▪ A combination of these problems, or any other problems which intensify risk.
When considering client needs, case managers should assess potential risk factors for service
delivery and take appropriate actions. For example, if the case manager believes the client may
rapidly progress to a state of crisis then they may seek to prioritise crisis intervention in the
client’s case management plan. Similarly, case managers should consider all possible risks related
to the client engaging in any support services that they identify. Conducting risk assessments is
an important part of the case management process, particularly when working with clients with
co-existing needs. The goal of risk assessment is to assess any potential risk factors and respond
appropriately. The entire risk management process essentially consists of four steps:
1. Identify the risk
2. Assess the risk (i.e., likelihood and impact)
3. Implement an appropriate response to the risk
4. Monitor and control the risk
While risk assessment is part of any case management assessment, each organisation will have
their own requirements for it and organisations that work with some client groups may have
more specific procedures that need to be followed. Case managers must always be alert for
potential risk and be knowledgeable of their organisation’s risk management strategies.
Summary
When working with clients with co-existing needs, case managers need to consider a wide array
of issues impacting on their client, gather sufficient information about the client to develop a
detailed picture, and conduct an assessment of the client’s needs. In this section of the Study
Guide you have learned about how such information is collected. In the next section of the
Study Guide you will learn more about how case managers use this information to determine
appropriate services and supports for the client.
References
AIHW. (2014). National drug strategy household survey detailed report: 2013 (Cat. no. PHE 183).
Canberra, Australia: AIHW.
Bromfield, L., Lamont, A., Parker, R., & Horsfall, B. (2010). Issues for the safety and wellbeing of
children in families with multiple and complex problems. Melbourne, Australia: Australian
Institute of Family Studies.
Bromfield, L., Sutherland, K., & Parker, R. (2012). Families with multiple and complex needs: best
interests case practice model specialist practice resource. Melbourne, Australia: Victorian
Government Department of Human Services.
Gallet, W. (2010). Perceptions of Poverty: An Insight into the Nature and Impact of Poverty in Australia.
Produced by The Salvation Army Australia Southern Territory Social Programme
Department in conjunction with the Australian Eastern Territory: Gallet.
Graham, H., & White, R. (2011). Improving services to support recovery from comorbidity in Tasmania.
Salvation Army Bridge Program and University of Tasmania, Hobart, with funding from
25
Department of Health and Ageing under the Comorbidity Improved Services Initiative,
Hobart.
Johnson, P. & Keegan, D. (2012). Specialist Homelessness Services Case Management

Resource Kit 2012. Australia: NSW Department of Family and Community Services.
Mindframe. (2014). Mental Illness Facts and Statistics. Retrieved on 2016, February, 12 from
http://www.mindframe-media.info/__data/assets/pdf_file/0015/6009/Mental-
Illness-Facts-and-Statistics.pdf.
NADA. (2013). Complex needs capable: A practice recourse for drug and alcohol services. Retrieved from
http://www.complexneedscapable.org.au/care-planning.html.
Nichols, A., Mitchell, J. and Lindner, S. (2013). Consequences of long-term unemployment.

Retrieved from http://www.urban.org/research/publication/consequences-long-term-
unemployment/view/full_report.
Rankin, J. and Regan, S. (2004) Meeting complex needs: the future of social care. Retrieved from
http://www.ippr.org/files/images/media/files/publication/2011/05/Meeting_Compl
ex_Needs_full_1301.pdf?noredirect=1.
Western Region Health Centre (WRHC). (2013). Uncovering stories, making meaning: How the
Indigo Program delivers assessment and care plan services for Victoria’s Multiple and
Complex Needs Initiative (MACNI). Retrieved from http://www.wrhc.com.au/wp-
content/uploads/2013/07/Assessment-and-Care-Plan-for-clients-with-Multiple-and-
Complex-Needs-2013-Report.pdf.
Woodside, M. & McClam, T. (2013). Generalist Case Management: A method of human service delivery
(4th ed.). Belmont, CA: Brooks/Cole, Cengage Learning.
Assessment activities
Assessment activities relevant to this section of the Study Guide are contained in Section 1 of
your Assessment Book.
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Section 2
DETERMINING
APPROPRIATE SERVICES
27
Determining Appropriate Services

About this Section:
In this section you will learn how to:
− Consider service delivery and referral options from strengths-based perspective in
collaboration with the client
− Provide the client with service information and support their decision making process
− Encourage the client to advocate on their own behalf to access services
− Provide the client’s information to other services according to consent and
requirements
1. Reading E
2. Reading F
3. Reading G
In the last section of this Study Guide you learned about the process of identifying client needs.
In this section of the Study Guide you will learn about the process of matching client needs to
suitable services and providing for the delivery of services to address client needs.
Matching services to client needs

Appropriately matching client needs to relevant services is extremely important when working
with clients with co-existing needs. You have already learned about how such clients often ‘fall
through the gaps’ as a result of services inadequately coping with their needs. In addition, a
study that examined the effect of matching comprehensive services to client needs in five
domains (including medical, mental health, family issues, vocational or housing needs), found
that clients who had their full range of needs matched to appropriate services during drug
treatment showed the biggest improvement in outcomes (Friedmann, Hendrickson, Gerstein &
Zhang, 2004). This study demonstrates that clients (especially those with multiple or co-existing
needs) benefit greatly from suitable needs-service matching.
In order to adequately identify relevant services to address client needs, it is important to be

aware of the full range of services available. Generally, case managers are quite good at being
aware of what services are available within their own organisation, however, they are not always
so knowledgeable of external services. In order to adequately support their clients, case
managers may need to negotiate across a range of services. For example, case managers need to
gain and maintain knowledge of a wide variety of services, including:
▪ Employment services (e.g., employment organisations and job service agencies)
▪ Physical and mental health services (e.g., GPs, psychologists, clinics, counsellors)
▪ Housing services (e.g., government housing programs or housing support services)
▪ Community support services (e.g., specific services, programs and supports available for
particular client groups)
▪ Social inclusion services or programs (e.g., day respite programs for carers of people
with a disability or reintegration programs for people who have been imprisoned)
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▪ Education and training services (e.g., specific programs or funding services)

▪ Financial support services (e.g., financial counselling services)
So how exactly, do case managers gain and maintain such knowledge? One key aspect of
effective practice is building professional networks.
Many services require a written referral form and some ask for an interview or both. If a
caseworker knows the person who does assessments for service entry, it can be much easier
to get across the client’s specific needs and how the other agency can best address them.
Therefore it is important for caseworkers to actively network with local services to develop
respectful professional relationships and get a sound knowledge of what each service can
provide clients. This can be done by arranging service visits and attending local interagency
meetings that are relevant to your client group.
Case managers should seek to become aware of the common service requirements of
programs/services in the local area and the basic features of those services, such as:
▪ The specific services they provide
▪ Eligibility requirements to qualify for the services
▪ Whether the service has availability for new clients
▪ Whether any fees are involved with the service.
Having knowledge of these areas and having strong contacts within networks can make the
identification of services outside the organisation’s reach much easier for case managers.
Remember, case managers will rarely be able to provide all required services for client’s with co-
existing needs within their own organisation, so it will be important to consider other services
that might also be suitable for the client and the client’s needs. In most cases, the first step in
planning will involve the case manager matching client needs to services available within their
organisation. It may have taken time to establish trust between the client and case manager, so
if there are suitable programs available within the case manager’s organisations to support the
client, then this is more desirable as the client will be more likely to engage with a known and
trusted organisation, rather than having to work with a new and foreign service. However, as
previously mentioned, most clients will require a collaborative and inter-agency approach. So,
the next step would then involve matching the client to any external services to help address
needs that your organisation cannot assist with.
Self-Reflection
Why is important for case managers to ensure that clients have access to other services that
meet their needs? What would be the harm of case managers ignoring any client needs that
cannot be met within their own organisation?
Case managers need to strike a balance between working within the scope of their own role and
expertise while ensuring that clients have access to services to have all their needs addressed –
even if that requires referral to other services outside of their organisation.
Sometimes a case manager may be uncertain about their assessment of client needs or their
identification of appropriate services to address client needs. This may be due to the case
manager’s experience or level of expertise in a particular area. Especially when working with
29
clients with co-existing needs, it may be difficult to root out the main issues or factors that need
to be prioritised and it is important for the case manager to be able to identify their own
limitations in assessing and addressing client needs. In this situation, assistance should be sought
from colleagues, senior workers, supervisors, or experts in the area. Some organisations will
have practice advisors who can provide consultation on case direction. By consulting about a
case, case managers can reflect on their own assessment, gain additional guidance, and learn
about other services or programs that are more appropriate.
Providing information and assistance

After the case manager has considered available supports and identified a range of relevant,
suitable, and available services, this information will need to be conveyed to the client. When
providing the client with relevant information on service options, the case manager needs to
ensure that they are doing so in a collaborative and strengths-based manner and are not being
Readings too directive. Case managers should discuss a range of available service options with the client.
E, F & G Client freedom should be maximised – remember, clients are free to decide which services they
do or do not wish to engage with.
Unless an individual’s capacity is in question or there is a concern that the safety of others
might be compromised, service users should have control over decisions about their own
lives.
(Bolger & Walker, 2014, p. 180)
Case managers should discuss all relevant services and supports with clients. Service selection
should be done in collaboration with the client. While the case manager may create a short-list
of services and organisations based upon the collaborative assessment of client needs, they
should discuss all relevant services with the client and facilitate the client’s empowerment by
allowing them to select the provider that is best for them.
Case managers should provide clients with service information in an open and unbiased way
and support their decision making processes. This may involve the case manager providing the
client with some informational material (e.g., pamphlets, fact sheets, informational flyers, or
application forms) so that the client can consider their options more fully before making a
decision. Additionally, most organisations will have information on their websites that a case
manager can direct a client to. Case managers need to be mindful of the best way to
communicate information with their client, as navigating social services can be a confusing
process for most people. For example, if the client has problems with memory, then they may
require information to be written down for them. Alternatively, if the client has an intellectual
impairment, the case manager will need to discuss the service options at a level that is
appropriate for the client. It is important to provide the client with all the necessary information
about a service so they are able to decide independently if they want to access a service.
Self-Reflection
Why do you think it is important for the client to have choices about services they access and
how they access them? What do you think the consequences of making decisions on behalf
of your client would be?
Once the case manager and the client have agreed on the particular services/supports that the
client would like to use as part of their case management plan, the case manager should consider
service delivery and referral options from a strengths-based perspective. This means that the
30
case manager should support the person as much as necessary, but no more than necessary, to
access services.
It is important for case managers to facilitate the client’s connection to other services but the
level of facilitation will vary from client to client. For example, in the case of high functioning
clients that only require one external referral, the case manager may provide the client with
relevant information and encourage the client to make contact with the organisation themselves.
For example, the case manager may provide the client with a summary of:
▪ The contact details of the organisation, including operating hours and preferred modes
of contact
▪ The nature of the service, including the approaches and methods of delivery
▪ What the client needs to bring to or have ready for their appointment
▪ What to expect on arrival
▪ The details of any up-front costs, payment methods, and rebates
▪ Relevant paperwork, forms, or other documents
Depending on the client’s capabilities, the case manager may also need to facilitate the client’s
access by making arrangements on their behalf (with their permission). They might also:
▪ Complete a referral and make an appointment
▪ Call the client before their appointment to discuss any concerns – this can help to
empower the client and encourage them to attend
▪ Arrange transport for the client to get to and from the organisation or service
▪ Arrange for someone (e.g., family member) to accompany the client if necessary
▪ Encourage the client to write the appointment in their diary or set a reminder in their
phone
▪ Follow up with the client after their appointment
Case managers should be mindful that clients with co-existing needs may require additional
assistance and support to access a service due to certain barriers (for example, a physical or
intellectual disability, a social anxiety, a language barrier, a drug abuse issue, etc.). Therefore,
case managers need to think practically about whether a client is able to access a service
independently or whether additional supports are required. However, at the same time, the case
manager should not underestimate the client’s abilities to act independently. It is important for
case managers to encourage clients to be as independent as possible, while providing any
necessary supports.
A note on self-advocacy
Case managers should encourage clients to be as independent as possible and engage in their
own self-advocacy.
What is Self-Advocacy?
Self-Advocacy is learning how to speak up for yourself, making your own decisions about
your own life, learning how to get information so that you can understand things that are of
interest to you, finding out who will support you in your journey, knowing your rights and
responsibilities, problem solving, listening and learning, reaching out to others when you need
help and friendship, and learning about self-determination.
(Wrightslaw, 2012)
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The best way that a case manager can encourage a person to advocate for themselves is to
provide them with all the necessary information so the client can make an informed decision,
and encourage them to make those decisions. “The hallmark of any strengths-based intervention
is choice” (McClam & Woodside, 2012). Encouraging clients to make their own decisions can
be an incredibly powerful force.
Some additional tips for promoting self-advocacy in clients include:
▪ Educate the client – arming your client with information is the first step to promoting
their ability to self-advocate.
▪ Believe in the client – understand the client’s strengths and promote them.
▪ Encourage the client to disagree with you if you are wrong or have misunderstood their
needs/desires – remember, the client is the expert on their life.
▪ Role model advocacy skills – show clients how it’s done and build their skills. For
example, if your client does not feel comfortable chasing up a missed appointment, or
wasn’t offered an adequate explanation of why they weren’t accepted into a program,
show them how it is done by contacting the service in front of the client so they can see
how you approach the situation. Be assertive, not passive or aggressive.
By building up a client’s ability to advocate for themselves, case managers can assist their clients
to develop as confident, effective individuals who are less likely to require case management
services – which is the ultimate goal of case management.
Documenting the case management plan and making referrals

Once the client has decided which services they want to engage with, the case manager will
document this in the client’s case management plan and make any referrals as needed.
The case management plan should clearly document which service/organisation will be
supporting the client with each of their needs. Documenting this clearly will help the case
manager keep track of the client’s plan and appropriately monitor services (monitoring will be
discussed in more detail in the next section of this Study Guide).
If a referral is required, the case manager will need to obtain the client’s written consent to make
the referral (e.g., a release of confidential information form) and complete all necessary referral
documentation in accordance with organisational requirements. In all cases, case managers need
to ensure that they discuss any proposed referrals with their client and obtain their consent before
making the referral.
Self-Reflection
Reflect upon what you have previously learned about the legal and ethical responsibilities of
case management practice. Why is it important to obtain the client’s consent to make a
referral? What might happen if a case manager did not obtain this consent?
When completing referrals it is important to be mindful of the information included and

terminology used in referral documentation. Sometimes case managers can resort to using their
own industry terminology or ‘jargon’ which can be a quick and effective way of communicating
within an organisation but does not allow for the full context of a client’s situation to be
communicated to external service providers. All referral documentation should be clear and
jargon-free. Additionally, it is important to continue to work from a strengths-based perspective
32
when writing referrals and emphasise the client’s strengths and assets in the referral, as well as
describing the client’s needs.
Many referrals convey the sense of hopelessness felt by the services around the client where
there is a sense that the client and the system are ‘stuck’ with all options exhausted. By
contrast, some referrals may hint at more hidden positive aspects of a situation, such as an
event that demonstrates the client’s resilience.
(WRHC, 2013, p. 11)
When a case manager contacts other service providers to make a referral, they will also
communicate any relevant language needs, cultural requirements, identified possible barriers,
and critical information (such as date of birth, eligibility data, Medicare, health insurer, transport
requirements etc.) that they have obtained throughout the assessment process that is necessary
to facilitate the other providers service provision. In most cases this information is documented
on the referral form. An example of the fields of a generic referral are included below.
33
Summary
In this section of the Study Guide you learned about the critical considerations and skills
required to identify and provide for the delivery of services to meet co-existing needs.
Specifically, you learned about the importance of identifying both internal and external services
to match client needs and working from a strengths-based, collaborative perspective when
discussing possible services with the client. In the next section of this Study Guide you will learn
how to evaluate service delivery and referral processes for clients with co-existing needs.
References
Bolger, J. & Walker, P. (2014). Models of assessment. In Lishman, J., Yuil, C., Brannan, J. &
Gibson, A. Social Work: An Introduction. (pp. 169 - 183). London, UK: Sage.
Friedmann, P.D., Hendrickson, J.C., Gerstein, D.R. & Zhang, Z. (2004). The effect of matching
comprehensive services to patients’ needs on drug use improvement in addiction treatment. doi:
10.1111/j.1360-0443.2004.00772.x.

McClam, T., & Woodside, M. (2012). The Helping Process: Assessment to Termination. Belmont,
USA: Brooks/Cole.
Western Region Health Centre (WRHC). (2013). Uncovering stories, making meaning: How the Indigo
Program delivers assessment and care plan services for Victoria’s Multiple and Complex Needs
Initiative (MACNI). Retrieved from http://www.wrhc.com.au/wp-
content/uploads/2013/07/Assessment-and-Care-Plan-for-clients-with-Multiple-and-
Complex-Needs-2013-Report.pdf.
Wrightslaw. (2012). Self-advocacy. Retrieved from

http://www.wrightslaw.com/info/self.advocacy.htm
34
Section 3
EVALUATING ASSESSMENT
AND REFERRAL PROCESSES
35
Evaluating Assessment and Referral

Processes
About this Section:
In this section you will learn to:
− Seek feedback about assessment processes from the client and other networks
− Monitor processes and their outcomes in terms of success in meeting the client’s needs
− Routinely seek feedback and reflect on own performance
− Use feedback and own evaluation as a basis for improving processes
1. Reading H
In the previous section of the Study Guide, you learned about the importance of correctly
identifying and matching services to address client needs. In this section, you will learn how to
evaluate assessment and referral processes as well as your broader service delivery and
effectiveness as a case manager.
Monitoring assessment and referral processes

Once a case management plan has been developed and appropriate referrals made, case
managers must monitor the client's plan and the services being provided in order to ensure that
it is meeting the client's needs. This not only involves discussing the client's progress with the
Reading H client themselves, but also with the other service providers involved in the client's case
management plan.
Case managers should seek feedback from the client (and where relevant their families and
carers) about their experiences during the assessment process, whether there are any needs or
issues that have not been adequately addressed, and whether support services are being supplied
as planned. Case managers should also seek feedback from other professionals involved in the
client’s case management plan about the appropriateness of any referrals made.
Seeking feedback can take two key forms:

1. Informal feedback. This involves any conversations or feedback provided outside of
formally planned evaluation processes. Case managers should be in regular contact with
clients and other services involved in the plan – this will provide regular opportunities
for feedback to be provided. A case manager should use all information provided to
help assess whether client needs are being addressed in an ongoing fashion. Clients with
co-existing needs may require closer monitoring and review, so case managers should
keep in regular contact with these clients and referred services to check progress.
Regular contact with the client is helpful to keep abreast of any potential problems or
issues and provide the opportunity to suggest possible solutions or remedies to barriers
before they become too problematic. Regular contact will also help to maintain rapport
with the client and may assist the client to engage more effectively with the service or
36
smooth over any issues that are occurring. This contact can take a variety of forms,
whether it be phone calls, emails or face-to-face meetings. Of course it is important to
ensure that all information is gathered and shared in accordance with organisation
procedure (e.g., seeking client consent and documenting contacts).
2. Formal feedback. Formal review of services are planned reviews. These can involve
having clients and other professionals complete feedback forms (or other formalised
review documentation) or can involve formal case review meetings. The frequency of a
formal case review will vary between organisations and between different sectors.
Clients with co-existing needs may require more frequent service reviews. For example,
the homelessness sector recommends that “caseworkers should aim to formally assess
client needs at least every 3–6 months. Any less and the case plan may become
ineffective and irrelevant.” (Johnson & Keegan, 2012, p. 59). If the client has particularly
pressing needs or is in a state of potential crisis, more regular review may be warranted.
A formal case review is essentially a meeting with the client and other significant people
involved in the client’s case to check the client’s progress according to the case plan. It
provides an opportunity to celebrate progress made by the client and identify any
barriers or issues that are hampering the client’s progress. These meetings should
involve all of the key stakeholders, including:
− The client
− The case manager
− Significant family members
− Relevant support workers and other professionals
Self-Reflection
Why do you think it is important to review services formally and informally? What is the
advantages and disadvantages of both?
Ultimately, case managers are interested in obtaining feedback from the client and other services
about whether the client is on-track towards achieving their needs/goals as defined by their case
management plan. Monitoring progress can be thought of as a fairly straight forward process in
which the case manager reviews the client’s goals, assesses how the client is progressing towards
these goals, notes any achievements, notes any barriers, and seeks input from both the client
and the service providers involved on how they feel the process is going. Of course, just like
the other aspects of case management, the theory is often easier than the practice. One critical
aspect of the monitoring process that many beginner case managers struggle with is how exactly
to monitor the client's progress towards goals. Obviously, this process is easier if the case
management plan is well defined in the first instance. Case managers and clients should discuss
review mechanisms and timeframes and tools that will be used to assess progress towards goals.
These tools will vary depending upon the nature of the client’s goals but can range from the use
of client self-report through to the use of standardised behavioural inventories.
Another technique that case managers can use to help monitor the client’s progress and the
effectiveness of case management processes in meeting the client’s needs is a SWOT analysis.
What is SWOT? It is a tool designed to break up and analyse something into key parts. SWOT
is an acronym for strengths, weaknesses, opportunities, and threats. This technique requires case
managers to consider, in turn, each of the client's goals and needs and conduct a SWOT on
each. Ultimately the case manager asks themselves what are the strengths of the client's case
management plan, what are its weaknesses, what opportunities are there, and what threats are
37
there. Case managers might also ask these questions of the other service providers involved in
the client's case. For example, they may ask:
Strengths: Weaknesses:
▪ What is the client doing well? ▪ What areas is the client not doing well
▪ What are some of their strengths you in?
have identified? ▪ What are some of their perceived
▪ What is working well? weaknesses?
▪ Was is not working?
Opportunities: Threats:
▪ What could help the client do better? ▪ What is stopping the client from
▪ Has the client raised anything that could reaching their goals?
lead to improvements? ▪ What barriers have you observed?
▪ Can you think of anything that would ▪ Has there been any sources of conflict
help the client to reach their goal? between you/your service and the
client?
Using this tool can help outline what has been achieved/met (strengths), what areas require
additional resources/focus (weaknesses), what other opportunities/resources can be drawn
upon to improve the plan (opportunities) and what might be impacting upon the effectiveness
of the plan now or in the future (threats). This can help the case manager assess if anything
within the case plan needs to be reviewed, updated, or changed. While case managers might use
this as an internal tool, any changes made to the case management plan must be made in
collaboration with the client. For this reason, many case managers find it useful to work with
the client to conduct an overall SWOT analysis.
Using the SWOT tool with a client requires them to have an appropriate level of verbal ability
and self-assessment. Of course, there are a range of other alternatives available when working
with clients with lower developmental statuses. For example, when working with children or
young people, the case manager might use charts or graphics to help the client reflect upon their
perception of progress towards goals. Some examples of these types of tools are included below:
Child aged 5-10
Colour in
the
picture
for how
well you
did this
week
38
Youth aged 10-15
Ultimately, the options for monitoring and reviewing a client’s progress are only limited by the
case manager's imagination.
Case managers need to monitor client progress in order to appropriately adapt the case
management plan to any changing needs or circumstances of the client. In some cases this might
involve seeking further support services in cases where the client is not making the expected
progress. In other cases it might involve altering the levels of existing service provision. Of
course, the exact changes required will depend upon the client’s individual needs/barriers.
Ultimately, the case manager will need to work with the client to determine the most appropriate
response in cases in which desired progress is not being made.
It is important for case managers to monitor for any changes in a client’s circumstances and
adjust the case management plan as needed. This is particularly important when working with
clients with co-existing needs. As outlined in Section 1 of this Study Guide, case managers need
to be aware of the multiple issues in a client’s life and how these issues impact on one another
(that is, the client’s mental and physical health, substance use, imprisonment history, etc.). For
example, a client may lose their job, have a relapse in drug use, or have a relationship breakdown.
Alternately, a client may have a positive change in their circumstances. Perhaps they may meet
a new and supportive partner, gain employment, or feel they no longer require support. In either
situation, the case management plan will need to be adapted.
It is highly likely that the client’s needs will change throughout the course of supporting them
in case management. In fact, caseworkers should expect things to change and therefore
develop a flexible approach to case management to manage this. Effective caseworkers are
able to update and adapt their work as the needs of the service and their clients change.
39
When adapting to the changing needs of a client is no longer possible, the service your
organisation provides may cease to be suitable for them. Alternatively, a client may stop
progressing towards their goals and be resisting casework assistance.
In these cases, it is useful for the caseworker to find out the reasons for the change and
evaluate what may need to be done differently to get things moving in the right direction
again. Sometimes there may be things getting in the way of the client moving forward that is
causing them to avoid certain situations or aspects of the case plan. Sometimes it may be the
caseworker themselves that is causing the blockage.
Most organisations will have procedures in place for ensuring that client circumstances are
routinely recorded, such as conducting regular reviews and ensuring case notes are recorded and
kept up-to-date. This is to ensure that any changes that occur are recorded and monitored,
which will assist in tracking the progress (or decline) of the client. This includes recording
decisions made and the reasons for these decisions, which will protect case managers from
scrutiny if a poor outcome occurs and a case manager is criticised for their handling of the case.
Assessment is an ongoing process of identifying and re-evaluating the needs of clients and
should never become a static process. In some ways, caseworkers are best to expect and plan
for the unexpected in their work with clients. This can be done by building in regular review
processes and working with the client to develop their problem-solving skills that they can
apply in a variety of situations.
Caseworkers should never stop assessing the needs of their clients. The information a
caseworker gathers from ongoing discussions and observations helps to inform the planning,
action and review components of case management.
Case managers should never assume that everything is going to go according to plan. However,
by keeping in regular and close contact with their clients and other significant people in the
client’s life (such as family, other professionals and support workers), case managers can help
keep everything on-track for the client as much as possible.
Collecting client feedback on your own service provision

Case managers should not only review the client’s progress, they should also routinely seek
feedback on their own work in order to reflect upon their processes and performance. Case
managers should gather feedback on their organisation’s overall processes as well as their own
individual work with clients:
▪ Feedback on the organisation’s processes. Most organisations will have specific
procedures for collecting feedback from clients and other networks in regard to their
service provision. Such feedback is designed to help organisations increase efficiency,
improve positive outcomes for clients, and help determine which elements of programs
are effective or ineffective (Hepworth, Rooney, Rooney, Strom-Gottfried & Larsen,
2010). Organisational feedback can be received in a variety of formats, including:
- Clients supplying feedback about the organisation through the case manager who
then passes this onto their supervisor
- Clients completing standardised feedback or complaints forms
- Anonymous feedback options (e.g., suggestion boxes, online feedback forms)
40
- Standardised questionnaires provided to clients, other organisations who regularly

work with organisational clients, and members of the community.
▪ Feedback on the case manager. Case managers should be constantly seeking to

improve upon their practice by seeking feedback from clients, colleagues, and senior
staff and engaging in reflective practice and supervision. This feedback can come in the
form of informal chats or by asking clients (or others) to fill out formal feedback forms.
It is important to note that when seeking out client feedback it is useful to inform clients
that any feedback that they give will not have a negative effect on their ability to receive
services or be prioritised for programs. As clients with co-existing needs may be more
difficult to engage or have a negative opinion of services, it is important that the request
for feedback is sought in the spirit of continuous and ongoing service development.
An example of a client feedback form that gathers feedback on both the organisation as a whole
and the individual worker (in this case a counsellor, but similar questions could be asked in a
case management context) is included below.
(Source: Sufittop, 2016)
41
Self-Reflection
Case managers and case management organisations usually collect feedback using a variety of
formats (e.g., verbal feedback, formal feedback forms, online feedback, etc.). Why do you
think it is important to collect feedback in a variety of formats? What benefits do you think
this might have?
By gaining feedback, case managers will be able to develop new skills and knowledge that will
improve their effectiveness as case managers. Indeed, improving skills and knowledge should
be at the forefront of a case manager’s mind and they should seek out opportunities for self-
improvement at every avenue.
It is important that case managers evaluate the feedback that they receive and reflect upon it in
relation to their practice. A case manager may take note of any patterns that demonstrate their
need for improvement in any particular area and plan to improve their skills and knowledge.
For example, if a case manager were to receive feedback that they were unknowledgeable on
issues related to particular client groups, they should seek to develop themselves in that area
(e.g., they may decide to do some individual research and study to improve their knowledge, or
they may participate in training on engaging with such clients). Alternately, a case manager may
receive positive feedback on a certain area of their practice. Knowing that they have a strength
in a particular area can also be useful.
Good client feedback processes are important for the efficiency of how community services
organisations function. It demonstrates to the client that their opinion matters and can help
both case managers and organisations determine which elements of their procedures or practice
are effective and which are detrimental.
Client feedback gives important information about what works and what doesn’t work in the
casework support and other services your organisation provides. Client feedback, if done well,
also empowers clients to have a say in how the organisation delivers support. Client feedback
should therefore be used to guide service development and measure effectiveness.
Particularly as clients with co-existing needs are often found to ‘fall through the gaps’ of services,
client feedback is crucial to ensure efficient case work is being performed. Evaluation should be
incorporated into organisation procedure and viewed as a “cycle of ongoing development and
improvement of services” (AIFS, 2013).
Summary
Evaluating client service delivery is very important to ensure that client’s co-existing needs are
continuing to be addressed. Evaluating client service delivery involves collecting client feedback
on service delivery and identifying opportunities for improvement. In this section of the Study
Guide you learned about some of the key processes case managers use to evaluate case
management processes.
References
Hepworth, D.H., Rooney, R.H., Rooney, G.D., Strom-Gottfried, K. & Larsen, J. (2010). Direct
social work practice: theory and skills. Belmont, USA: Brooks/Cole.
42
Sufittop. (2016). Customer Feedback Form Template. Retrieved from http://sufit.top/sample-

customer-feedback.html
43

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Assess co-existing needs

DIPLOMA OF FINANCIAL COUNSELLING

All Case Histories in this text are presented as examples only

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Australian Institute of Professional Counsellors

How to Use This Study Guide

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Element Performance Criteria

4. Complete reporting 4.1 Document the outcomes of the assessment process

Section 2: Determining Appropriate Services

Section 3: Evaluating Assessment and Referral Processes

Identifying a Client’s Co-Existing Needs

Understanding a client’s co-existing needs

▪ Culture and religion

Source: NADA, 2013

Information gathering for assessment

▪ Existing case documentation (e.g., referral forms, intake documents, existing

▪ Other professionals/specialists. Case managers might seek out information from

2. Domain based assessment: the purpose of a domain based assessment is to understand

Analysing and assessing client information

Analysing client information in order to determine service requirements often involves a

(Bromfield, Lamont, Parker & Horsfall, 2010)

In general, the order of priority should include:

Client eligibility for services/supports

The complexity of client needs

Johnson, P. & Keegan, D. (2012). Specialist Homelessness Services Case Management

Nichols, A., Mitchell, J. and Lindner, S. (2013). Consequences of long-term unemployment.

Determining Appropriate Services

Matching services to client needs

In order to adequately identify relevant services to address client needs, it is important to be

▪ Education and training services (e.g., specific programs or funding services)

Providing information and assistance

Documenting the case management plan and making referrals

When completing referrals it is important to be mindful of the information included and

Johnson, P. & Keegan, D. (2012). Specialist Homelessness Services Case Management

Wrightslaw. (2012). Self-advocacy. Retrieved from

Evaluating Assessment and Referral

Monitoring assessment and referral processes

Seeking feedback can take two key forms:

Child aged 5-10

Youth aged 10-15

Collecting client feedback on your own service provision

- Standardised questionnaires provided to clients, other organisations who regularly

▪ Feedback on the case manager. Case managers should be constantly seeking to

(Source: Sufittop, 2016)

Johnson, P. & Keegan, D. (2012). Specialist Homelessness Services Case Management

Sufittop. (2016). Customer Feedback Form Template. Retrieved from http://sufit.top/sample-

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