Care and Support Project

Use Case Summaries

11th June 2019
Use case status
Use case Stage Comments
Care referral Final draft
Care referral response Final draft
Referral outcome feedback Final draft
Case file Final draft
Customer risk assessment Final draft
Aggregate case metrics Final draft
Customer needs assessment Final draft
Care services Final draft Need to consider defining
library of specific referral
forms and/or service criteria
frameworks
 Summary process map
x Use case numbers (see following slides)

Care and Support: Case management

Case lifecycle Service catalog maintenance

Referrer
Note services
Make referral offered with criteria
and referral form

Customer
Self-referral (e.g. via Receive advice on Receive and agree
contact centre) where to get help action plan

Triage Team 1

Accept case? No

7
Customer 5 6
Needs Customer
Yes Aggregate
Assessment Risk Case File
Case Metrics
Assessment Yes
Case Owner

4
Produce (or update) No Note services
Execute/refer Share plan with Transition or close Review/evaluate
Gather information Asses case and risks and agree Action Case complete? offered with criteria
individual actions relevant teams case case and report
Plan and referral form
Other Internal
Function

3 Coordinate with
Provide outcome Carry out
Case Owner 2 1
feedback intervention
regarding Customer

1 2
Provider
Service

Provide outcome Carry out Care services

Accept case
feedback intervention offered
Use cases
1. Care referral (data exchange)
2. Care referral response (data exchange)
3. Case outcome feedback (data exchange)
4. Case file (data model)
5. Customer risk assessment (data model)
6. Aggregate case metrics (data model)
7. Customer needs assessment (data model)
8. Care services (data model/data exchange)
1. Care referral (data exchange)
A request for care and support services. Also known as an “application” or
“support request”. This may be inbound (i.e. where someone is requesting a
support service) or outbound, for example resulting from screening (to a more
appropriate service/agency), for a specific part of an action plan in an on-going
case, or a transfer. Must take account of agency/service criteria as appropriate.
Inbound from: Inbound to:
• Self-referred (including via Choice-Based Lettings/sheltered) • Tenancy sustainability
• Internal, including: Neighbourhood team, Finance/income • Supported/sheltered housing
management, Contact centre – where not explicitly a self- • Contact centre
referral/request for support but instead identified by the Outbound to:
contact centre, Repairs operatives (observation of need whilst • Statutory sector - GP, social services,
conducting repair), Inspections (as part-of planned fire service (e.g. smoke detectors),
maintenance) police (e.g. crime)
• External, including: Statutory services (LA, police, fire, GP etc.), • Private care providers
Members of the public, neighbours or family, Voluntary sector, • Commercial partners – e.g. utility
Commercial partners providers with grants, affordable
Outbound from: warmth
• Screening triage team • Internal – e.g. to an energy initiatives
• Case owner officer
• Action plan • Citizens’ Advice Bureau, welfare advice
Potential benefits of implementing this use case:
• Work with one source of information, one version of the truth about the customer
• Set clear, consistent expectations of referrers based on a core data set that is extensible depending on the
referral type
• Consistent definitions across all internal teams
• Reduce the time before requests for information from external agencies can be issued (e.g. police or health) so
that these potentially lengthy processes (often due to data privacy) can be started as early as possible
• Opportunity to reduce data entry for both referrers and housing provider functions be a direct electronic
transfer between the respective systems
2. Care referral response (data exchange)
Response from a Service Provider on receipt of a Care Referral detailing whether
the referral was accepted (and if so, what are the expectations of next action
and the estimated or actual date of service commencement), or refused (with
the reason for refusal).
From: To:
• Statutory sector - GP, social services, fire service (e.g. smoke detectors), police • Screening triage team
(e.g. crime) • Case owner
• Private care providers • Other referrer
• Commercial partners – e.g. utility providers with grants, affordable warmth
• Internal – e.g. to an energy initiatives officer
• Citizens’ Advice Bureau, welfare advice
• Housing Provider support service
Potential benefits of implementing this use case:
• Automate the update of the referrer’s case management system with service providers initial response
• Enable reminders to be set or alerts generated relating to service commencement
3. Case outcome feedback (data exchange)
Information from a service provider to whom a request, case or action plan item
has been referred that describes the outcomes. This might be a single outcome,
or a series of steps towards a case closure (e.g. Personal Independence Payment
application submitted, or welfare benefits obtained).
From: To:
• Service provider/agency to • Case owner
whom original request was
referred
Potential benefits of implementing this use case:
• Save time and effort of chasing service providers for updates
• Earlier incorporate of the impact and outcomes of interventions delivered by service providers into the case
action plan
• More accurate and timely feedback to customer on their case
4. Case file (data model)
Descriptions of a specific case, including the assessments, action plan (aka “care
plan” or “wellbeing plan”), interventions, review and evaluations, and other
documents. The care file will typically include a risk assessment (see separate
use case) and details of the actions and responsibilities in an action plan
(included directly in this use case).
Used in:
• Sharing with the customer/client
• Transition or referral to another service/agency
• Internal awareness and coordination
Potential benefits of implementing this use case:
• A consistent format for describing cases across all departments and functions
• A consistent basis for information to support referrals
• Enable improved benchmarking, internal reporting, and comparisons across the various care & support
functions
• Establish a consistent, controlled formal record that can be used for case archival
• Greater clarity of recording and sharing who (individual or service) is responsible for specific actions
• Support the mapping of existing data held in other systems to a common standard format
5. Customer risk assessment (data model)
Describes a risk assessment for a specific customer and any reviews/revisions.
This typically informs the action plan.
There may be a standard for this already – this is being checked.

Used in:
• Case assessment

Potential benefits of implementing this use case:

• This data model use case has similar benefits to the action plan use case – for example pulling in data from other
system, like a credit reference agency to support a financial risk assessment
• Knowing what to ask reduces the risk of missing out something important
• Record who does each part of the risk assessment

It is thought that there may be some standards in this area (perhaps for specific types of risk
assessment) – please check internally to see if your SMEs are aware of these standards.

There is also the potential to include other assessments – for example financial assessment
to consider an individual’s changing financial situation.
6. Aggregate case metrics (data model)
Establishes a set of metrics that can be used to measure and classify a collection
of cases, for example distribution of cases by type (number of falls etc.). This
data can be used in reports or analysis.
These may be focussed on specific areas, for example regulatorily required
metrics, dementia, and extra case services

Used in:
• Board reporting
• Evidence to support bids (e.g. to CCG)
• Performance monitoring (both internally and as part of contract performance)

Potential benefits of implementing this use case:

• Easier and consistent ability to measure progress, which supports benchmarking, change transformation, bids
and, monitoring of internal and external performance
• Potential to inform national health and housing agenda be reliable and consistent metrics

There may already be some of these prescribed or defined at the Greater

Manchester level – for example by the council, Digital and Data initiative,
and/or CCGs.
7. Customer needs assessment (data model)
The record of the assessment of a service user/customer’s needs. This is
typically completed with the service user in the early stages of a case and
reviewed.
Used in:
• Case assessment
Potential benefits of implementing this use case:
• Adopt best practice across the industry for needs assessment for a variety of care and support services
• Improving assessment is likely to lead to more effective care and support provision and better outcomes
• Industry-wide standards for common needs assessment will improve overall understanding and skill in the
workforce
8. Care services (data model/data exchange)
A description of a set of one or more care services including the service criteria
and the required information to be included on a referral form (service user
details, consents, declarations, eligibility and other questions/assessment
information).
From: To:
• Service Provider, e.g. • A referring agency
• Statutory sector - GP, social services, fire service (e.g. smoke detectors), (for example a
police (e.g. crime) Housing Provider)
• Private care providers
• Commercial partners – e.g. utility providers with grants, affordable
warmth
• Internal – e.g. to an energy initiatives officer
• Citizens’ Advice Bureau, welfare advice
Potential benefits of implementing this use case:
• Provides a clear, standardized description of the service criteria to help avoid incorrect referrals and referral
refusals.
• Ensures the correct information is provided on a referral, reducing the likelihood of supplemental questions
being needed and the likelihood of providing more personal or sensitive information than is required.