Includes elements of case management, changes as a result of Keep Them Safe and case management in operation
Changes as a result of Keep Them Safe
The Special Commission of Inquiry into Child Protection Services in NSW and Keep Them Safe recognises that child protection is everybody’s business. There are eight principles that guide child protection in NSW. These are:
- Child protection is the collective responsibility of the whole of government and the community.
- Primary responsibility for rearing and supporting children should rest with families and communities, with government providing support where it is needed, either directly or through the funded non-government sector.
- The child protection system should be child focused, with the safety, welfare and wellbeing of the child or young persons being of paramount concern, while recognising that supporting parents is usually in the best interests of the child or young person.
- Positive outcomes for children and families are achieved through the development of a relationship with the family that recognises their strengths and their needs.
- Child safety, attachment, wellbeing and permanency should guide child protection practice.
- Support services should be available to ensure that all Aboriginal and Torres Strait Islander children and young people are safe and connected to family, community and culture.
- Aboriginal and Torres Strait Islander people should participate in decision making concerning the care and protection of their children and young persons with as much self-determination as is possible, and steps should be taken to empower local communities to that end.
- Assessments and interventions should be evidence-based, monitored and evaluated.
As a result Keep Them Safe represents a change in perspective and practice for many workers who come into contact with children, young people and families.
So what does this mean in practice?
In NSW child protection is everybody’s business and not just the responsibility of the Department of Family and Community Services, Community Services. This includes other NSW Government departments and non-government organisations across the universal, secondary and tertiary service continuum.
As the safety, welfare and wellbeing of children and young people is paramount, organisations and workers within this broader child wellbeing and child protection system must adopt a child-centred perspective in their practice. This means that the needs of the child or young person are placed at the centre of all decisions and services.
This may present some challenges because it could involve changes in concepts, such as “who is my client” and changes in practice, for instance “how does this impact what I do”?
Adult focussed services have an essential role in child wellbeing and protection because they are designed to address issues that are, or could, affect the adult’s parenting capacity. For example, a Family and Domestic Violence worker’s primary client in most circumstances is an adult. However when the adult client has children, the Family and Domestic Violence worker is also required to consider and address issues affecting the safety, welfare and wellbeing of the children.
What is case management?
The focus of the Child Wellbeing and Child Protection – NSW Interagency Guidelines is on children and young people. While an organisation may provide services to a parent e.g. mental health services, the Guidelines are only intended to provide assistance and/or guidance where there are concerns about the parent’s capacity to ensure the safety, welfare or wellbeing of their child.
Case management is a process whereby an individual and/or family’s needs are identified and services are coordinated and managed in a systematic way. The core elements of case management include assessment, case planning, implementation (service delivery), monitoring and review.
In the context of the Guidelines case management aims to improve outcomes for vulnerable children, young people and families through integrated and coordinated service delivery.
Effective case management may require organisations to work collaboratively to support children, young people and their families/carers. Children, young people and their families within a child wellbeing or child protection context may have complex and multiple needs and may require the support of a number of different services or organisations. Not every family will require multiple services and a coordinated approach, however, rarely do families where there are safety, welfare or wellbeing concerns about their children present with only a single issue. Collaborative work promotes multidisciplinary assessment, identification of gaps and duplication in service delivery and more efficient use of resources.
Principles of good case management
Effective case management in a child wellbeing or child protection context is based on the following principles.
- The safety, welfare and wellbeing of the child or young person is of paramount concern, however the provision of services to parents or carers is an important protective function for children and young people.
- Realising positive outcomes is more likely with the active participation of the child, young person and their family. It is important to ensure that engagement is meaningful, age appropriate, culturally relevant and appropriate for people with disabilities.
- Self determination is an important principle for all children, young people and their families and case management should actively support this principle.
- Case management needs to be designed and implemented in a culturally appropriate way and where possible led by Aboriginal or culturally and linguistically diverse (CALD) workers in order to effectively engage the family, local community and organisations. This includes taking into account access and equity issues.
- Being collaborative and involving relevant organisations ensures that needs are identified and responded to in an efficient way that avoids people having to “re-tell” their story, self-navigate through the service system and receive multiple assessments. A collaborative approach can minimise gaps, avoid duplications and promote the efficient use of resources.
- Goals and strategies are recorded and monitored for progress and arrangements are reviewed to ensure continued appropriateness.
Elements of case management
The process of case management is interactive and goal directed with an emphasis on monitoring and review to ensure that services are being delivered and the identified needs of the child, young person and family are being met.
The primary elements of case management are:
Assessment is a dynamic and ongoing process of gathering and analysing relevant information to determine appropriate support services.
Due to the often complex nature of the issues facing children, young people and their families assessment is not always a single event or a linear process. Assessment occurs at different times throughout case management. Workers need to be flexible so that they can identify and respond to developments as they arise and adjust goals and strategies as appropriate.
Assessments should lead to a decision about the risks, strengths and needs of the child, young person and their family. Where possible they should involve the child, young person and family. The assessment process should inform the development of a case plan.
Assessments generally start with gathering and analysing information. This process may be undertaken without direct contact with the child, young person or their family, and may include:
- assembling relevant and accurate historical information to assist with understanding the child, young person, their family, other significant people and their circumstances
- sharing information with other organisations relating to the safety, welfare or wellbeing of a child or young person
- identifying other workers and organisations who are, or have been, involved with the child, young person and their family (e.g. relatives, teachers, child care workers or general practitioner) and working collaboratively with them
- identifying the strengths of the child, young person and their family and determining how they can be best utilised.
After the collection and analysis of information the assessment process should include meeting the child or young person and their family. However, it may not always be possible or appropriate to meet all family members.
Whatever the circumstances, it is very important that at a minimum the children are “physically sighted” during the assessment process.
Case Study No: 1
The Child Protection Helpline received a report that April Nguyen, mother of four children aged between 2 and 11, had attempted suicide in front of the children.
The Helpline conducted a child protection history check of Community Services records. It identified previous involvement with the family in 2007 when April was scheduled under the Mental Health Act 2007 with severe post natal depression. At the time her husband, Trinh was able to care for the children while April was hospitalised. However, Trinh was also suffering depression at the time and health workers were concerned this may impact on his ability to care for his children.
The records also showed that the family had migrated from Vietnam five years earlier and had limited ability to speak and understand English.
The records noted that following the 2007 report, various services were engaged to assist the family, including Acute Care, the local mental health team and the Transcultural Mental Health Service. The family received support from local charities with housing, bedding, clothing and food. They also received Centrelink benefits.
The new report was allocated to the local Community Services Centre and a caseworker contacted the services which had earlier engaged with the family to obtain an updated report. She also contacted the children’s school and consulted a multicultural caseworker for advice about culturally appropriate practices and services.
These discussions provided several new pieces of information, including that April had been scheduled again and it was unclear how long she would remain in hospital. The caseworker was told that Lily, the oldest child, had intervened in her mother’s suicide attempt. Discussions with the school noted concern over the children’s level of attendance and participation in school activities.
The caseworker interviewed the children at school and heard from Lily that she is the main carer for her siblings and responsible for keeping the house clean, washing clothes and cooking most meals, even when her mother is at home. Lily appeared anxious about her mother’s wellbeing and upset that her father spent most of his time in his bedroom on the computer.
Caseworkers then conducted a home visit with a Vietnamese multicultural caseworker. At the visit the father, Trinh appeared defensive and minimised the concerns raised. He confirmed that April was still in hospital but disputed that Lily was responsible for maintaining the household. The home was well maintained. During the visit all of the children were sighted. Anh, the two year old, appeared weary and withdrawn.
The outcome of the caseworker’s safety assessment was that there were no immediate safety concerns for the children, however ongoing support for the family was required.
An interagency meeting was convened and workers discussed the family’s strengths including that they had previously successfully engaged with services and had the support of extended family.
It was agreed that child care for Anh, social activities for Lily and parenting and counselling support for Trinh would assist the family and culturally appropriate services were identified. Lily’s household responsibilities were discussed and the Vietnamese multicultural caseworker clarified that while it is culturally acceptable for Vietnamese children to have some household responsibilities the extent of Lily’s duties were not culturally appropriate.
After a risk assessment the following week a case plan was formulated. It specified the role and responsibility of each organisation and the expectations of Trinh in relation to ensuring the ongoing safety and wellbeing of the children.
Organisations who provide services to adult clients should as part of their assessment process determine whether the client has children in their care. If they do, arrangements should be put in place for the assessment of the child or young person, whether by your organisation or with the assistance of another organisation.
The children’s circumstances need to be assessed to determine if there are any concerns about their safety, welfare or wellbeing and whether additional services are required. All plans must take into account the needs of the children.
Information on preparing to engage and your first visit can be found in the Engaging Children, Young People and Families chapter.
Planning is a key component of the case management process and guides the work to be undertaken with the child, young person and their family. This is an interactive process that should involve all stakeholders, in particular the child, young person and their family.
The case planning process builds upon assessment and identifies what is required to address the physical, emotional, educational, social and cultural needs of the child, young person and family.
A case plan should be an individualised, comprehensive document that looks at all aspects of wellbeing and be based on relevant, factual information. It should utilise professional judgement and be prepared with the child or young person, their family and relevant organisations.
It should document what the goals are, the strategies needed to achieve those goals, the timeframes for the implementation of services and achievement of goals, as well as the role and responsibilities of all stakeholders, including the family. The intended outcomes for the family (i.e. what does success look like) should be clear and in plain English for all participants to understand. The language should be positive and strengths-based.
The goals and actions must be realistic and achievable within specified timeframes and available resources, whether they are immediate, short-term or future focused. They should ideally be mutually agreed upon by the child, young person and their family, though this may not be possible in all circumstances.
Copies of the case plan should be given to all stakeholders, where appropriate.
Case Study No: 2
Jim is a young father has recently taken on the fulltime care of his three children, Mathew (8), Sarah (6) and Dennis (2).
Jim has issues with alcohol misuse and is a client at an alcohol and other drug (AOD) service. Jim’s worker at that service contacted the NSW Health Child Wellbeing Unit (CWU) as they had concerns about Jim’s parenting ability.
The CWU checked the WellNet database and reviewed the child protection history which revealed issues including school attendance, lack of supervision, regular late night parties, children wandering the street late at night and Jim yelling and screaming at the children.
The children’s school advised the CWU that Sarah and Mathew’s attendance was poor, they were habitually late and often arrived without the necessary school materials and lunch.
A referral was made to the local Brighter Futures program and following initial assessment the Brighter Futures caseworker scheduled a case planning meeting with the family, the alcohol and other drug worker, a school representative and Jim’s mother.
At the case meeting it was agreed that:
- the Brighter Futures caseworker would have case management responsibility
- Jim would continue to attend weekly alcohol and other drug sessions, which would be reviewed in three months
- home visiting would commence within two weeks, with twice weekly visits for the first three months, to assist Jim to develop a manageable routine to care for the children and keep up with the household duties
- Jim’s mother agreed to immediately begin looking after the children two nights a week
- the school representative agreed to provide extra support for Mathew and to help arrange after school care for both children within two weeks
- a ‘school attendance response plan’ was developed, whereby the school would notify the Brighter Futures caseworker if the children failed to attend school and this would trigger an immediate home visit by the Brighter Futures caseworker
- a child care placement for 2 year old Dennis would commence as soon as a vacancy became available
- Jim would limit social gatherings to when the children were with their grandmother
- Jim to go on the waiting list to complete a 12 week parenting program.
A case plan review meeting was scheduled for four weeks time.
The agreed upon outcomes of the case plan are:
- Jim continuing with his alcohol and other drug counselling and managing his alcohol consumption appropriately
- the children attending school regularly and achieving learning milestones
- proper maintenance of the family home, including an adequate supply of healthy food
- respite care provided by Jim’s mother twice a week
- social gatherings only held when the children are not home
- Jim providing appropriate care for the children, while knowing he can seek help when needed.
The Brighter Futures caseworker agreed to prepare the case plan and provide copies to all stakeholders.
Where the client is a parent or carer, the children will be an integral part of the case planning process. While there may be specific goals and strategies focusing on the adult, the ultimate goal must be the safety, welfare and wellbeing of the children.
Adult-focused services should consider their potential to impact on the safety, welfare and wellbeing of the children. For example, if a parent or carer requires drug or alcohol treatment in a residential facility then the impact on the child or young person in their care must be considered and addressed as part of the case plan. It is not sufficient to assume that the parent will address the issue on their own. Assessing your clients’ capacity to care for their child(ren) is essential.
The case plan may also need to include services for the children, even though they are not the primary client. If the parent or carer is receiving treatment for a mental illness, the children may need additional supports to ensure their safety, welfare and wellbeing. This may include counselling, child care, or assistance with leisure or sporting activities. Other family members who can provide support and guidance to the children may need to be identified and contacted.
Record keeping is an important responsibility to maintain accountability to the child, young person, their family and for the organisation.
In addition to any organisational requirements, the minimum requirements for good record keeping include documenting:
- meeting dates, locations and participants
- the child’s, young person’s and their family’s strengths and supports
- agreed goals, actions and timeframes
- roles and responsibilities
- progress of goals and strategies
- changes to goals, strategies and timeframes
- review dates
- contact with internal and external stakeholders.
There are specific legislative requirements for records about children or young people in care and the placement of Aboriginal children and young people. Further information is available in the Out-of-Home Care Service Provision Guidelines, NSW Out-of-Home Care Standards and section 14 of the Children and Young Persons (Care and Protection) Act 1998 (the Act).
Workers need to be mindful of the language used to record information and how this could be interpreted and used. Language should be respectful and non-discriminatory. Records should be specific, factual and capable of being substantiated. Observations, quotes and facts that have led to a particular conclusion should be recorded and there should be a clear rationale for decisions Information should be presented so that facts can be distinguished from hearsay, professional opinion and interpretation.
General principles for record keeping include:
- acknowledgement of opinion
All records should be kept secure at all times and mechanisms should be in place to ensure that only relevant workers have access to them.
Case meetings are a tool to assist with case management, where more than one worker is involved, whether within or across organisations. They are an important part of the process and may be held at various points in the case management continuum, depending on the needs of the child, young person or family, urgency and complexity of the family’s needs and changes in family circumstances. Case meetings may be held to:
- define the roles and responsibilities of workers and organisations
- agree on the primary/key worker for the case
- define the purpose, intent, and direction of the intervention
- discuss an assessment
- develop a case plan
- progress a case plan
- make decisions
- review goals/actions
- plan towards case transfer and/or case closure.
Depending on the purpose, case meetings may or may not involve the child, young person and their family. However, the participation of the child, young person, family and other significant people should be promoted along with the participation of other relevant organisations and workers, if required. Stakeholders that are responsible for strategies in the case plan must participate.
Information on facilitating participation can be found in the Engaging Children, Young People and Families chapter.
Case meetings should:
- be chaired by the worker or organisation with case management responsibility (this may need to be negotiated between organisations)
- include the child, young person and their family, where appropriate
- represent the views of all stakeholders, including those who did not attend
- occur at regular intervals in line with monitoring of agreed actions
- have a clear agenda
- have clear meeting outcomes
- be documented, recorded and disseminated by the worker or organisation with lead case management responsibility within an agreed timeframe.
Implementation is the process of putting the case plan into action and delivering or arranging the services identified in the case plan. Implementation may involve providing services directly and/or referring to other organisations.
All stakeholders need to understand their role and the role of others in the implementation process.
Implementation relies on regular communication with the child, young person, their family (including support persons) and relevant organisations to ensure that services are being delivered, goals are being met and changes in circumstances are taken into account. Further information about communication can be found in the Engaging Children, Young People and Families chapter.
When the needs of the child, young person and their family are complex, implementation may require the coordination of a range of services by the worker or agency with lead case management responsibility.
Implementing a case plan involves workers:
- being vigilant for changes in the family’s circumstances that may introduce or escalate the likelihood of suspected risk of significant harm (ROSH) to a child or young person
- working with kin, family, community members and local Aboriginal organisations
- respecting and accommodating cultural practices and disabilities
- understanding and respecting workers from other organisations, including their perspectives, priorities and processes
- considering whether the child, young person and their family members can realistically access required services, especially for extended periods
- initiating actions when a child, young person or their family starts to dis-engage from a service.
- using case meetings where appropriate, for example when:
- the child, young person or family unilaterally ceases contact with service provider(s)
- a case plan goal has been achieved and the service is no longer required
- circumstances change and/or additional needs are identified
- being aware that inter-organisational conflicts can emerge and being committed to resolving them if they do
- maintaining good records.
Case Study No: 3
Ellie and her former partner Ray are separated and have no current contact. They have three children, Brian (6), Lee (4) and Joanna (1).
The children’s school referred Brian to Ageing, Disability and Home Care (ADHC) for assessment. Brian was assessed as having a severe autistic disorder. Ellie also said she was exhausted, was having difficulty getting up in the morning and was feeling she could no longer manage Brian and care for her other children and herself adequately. The family needed a range of supports for Brian’s disability and Ellie’s capacity to parent and to manage Brian’s relationship with his siblings as well as to care for herself and her other children.
The ADHC worker completed the Mandatory Reporter Guide (MRG) which recommended that the worker contact and the case was determined to be non-risk of significant harm. The ADHC worker contacted the Family and Community Services (FACS) Child Wellbeing Unit (CWU) to report the child wellbeing concerns. As part of their assessment the CWU checked the WellNet database. The concerns were assessed as not meeting the risk of significant harm threshold and the CWU and the ADHC worker identified the following service needs:
- Brian required autistic support and speech therapy
- Ellie required a parenting support program designed for parents of autistic children
- Ellie required respite care for Brian
- Child care placements were required for Lee and Joanna
The ADHC worker together with the speech therapist, the school and the family to develop a case plan, under which the ADHC worker agreed to be the key worker.
The ADHC worker agreed to organise respite care and a speech therapist for Brian within four weeks. The ADHC worker also agreed to locate an appropriate autistic parenting support group for Ellie and supplied Ellie with details of an Autism Support Line.
Child care for Lee and Joanna was arranged, Brian’s school provided additional support for his special education needs and the ADHC worker agreed to liaise with Brian’s school on his progress.
Two days after the case meeting the ADHC worker contacted each of the service providers to confirm services. The ADHC worker secured a date for the commencement of respite care for Brian and found an appropriate autistic parenting support group for Ellie.
All service providers agreed to contact the ADHC worker if they had any concerns while the ADHC worker agreed to monitor any changes in the family’s circumstances.
The ADHC worker scheduled monthly case meetings which included Ellie and all service providers.
To maximise achievement of case plan goals the following should be considered as part of best practice:
- the child or young person and their family should drive the process as much as possible
- all workers and family members should know what each others roles and responsibilities are
- care should be taken to consider and identify services which are most appropriate to the needs of the child or young person and their family
- a clear and coordinated process that is inclusive and communicated effectively will help lay the foundation for successful implementation and the achievement of goals
- good progress notes should be maintained as proper record keeping will assist with monitoring and review
- any changes to the case plan should be recorded as agreed and the child or young person, their family, other significant people and appropriate workers/organisations should be advised of any changes that may affect them
- all contact with internal or external stakeholders should be recorded
- where there is any concern about the progress organisations should work quickly and collaboratively to resolve.
Monitoring is the ongoing review of the progress of implementation of the case plan for effectiveness and continued relevance. Successful case management relies on continuous monitoring to ensure that the case plan is improving the safety, welfare and wellbeing of the child or young person.
Monitoring will help to identify any barriers to achieving the case plan goals so that strategies can be introduced, or existing strategies modified to overcome them. It also helps to ascertain whether the child, young person or family’s needs have changed over time.
Monitoring can be done individually by all service providers and at least by the worker/organisation with case management responsibility.
It is also important to obtain regular feedback from the child or young person, their family and workers to determine whether:
- services are being provided in the manner specified in the case plan
- needs have changed
- there are any barriers to implementation
- a change in direction is necessary
- engagement by the family continues.
Case Study No: 4
Sara is the mother of 6 year old Suzie and 4 year old Ben. A Family Support Service began working with Sara after an incident of domestic violence against Sara and the children perpetrated by Sara’s then boyfriend, Paul.
After the assessment, a case plan was developed with Sara that included:
- Sara taking active steps to prevent Paul from returning to the family home by taking out an Apprehended Domestic Violence Order (ADVO)
- Sara and the children attending domestic violence counselling at the local community health centre
- Sara undertaking a 12 week parenting skills program with the Family Support Service
- a Family Support Service assisting Sara through twice weekly home visits and with help to maintain the family home
- enrolling Suzie in her primary school’s breakfast program and Ben in the school’s ‘transition to school’ program.
At the case planning meeting the Family Support Service and other organisations agreed that in addition to telephone contact as required, they would provide fortnightly reports which documented the contact, service provided and a brief progress update. As the key worker, the Family Support caseworker agreed to monitor the progress of the case plan.
Organisations also agreed to report to the Family Support Service caseworker if anything prevented the services being delivered or if the family’s circumstances changed. The Family Support Service caseworker undertook to address these issues quickly. The first case review meeting was scheduled for 4 weeks time.
About two months later the Family Support Service caseworker became aware that Sara had resumed her relationship with Paul and that he may be living with her.
The Family Support Service caseworker conducted an unannounced home visit with Sara. Sara explained that Paul “had changed” and wanted to resume their relationship. The Family Support Service caseworker told Sara that this was contrary to the ADVO and that Paul’s return could pose a risk to the safety, welfare and wellbeing of the children.
The Family Support caseworker then advised Sara that this change in circumstances would require a review of the current case plan, reapplication of the Mandatory Reporter Guide and could result in a report to Community Services.
The review process differs from monitoring in that it is collaborative and holistic. A review should be done jointly with all organisations that are providing services to the family.
Case plans should always include a review date and indicate any particular aspects to be reviewed. There should be regular formal and informal reviews of the case plan to ensure that outcomes are current and relevant to the needs of the child or young person and their family.
A good review should:
- be based on up to date information gathered from the child or young person, their family and relevant organisations
- provide evidence of achievements and how they relate to the original goals
- determine if the outcomes have made a difference to the safety, welfare and wellbeing of the child or young person
- note what was not achieved, what impacted on its success of otherwise and how these matters will be followed up in subsequent plans, as necessary
- provide information for subsequent planning, giving direction to new or emerging issues and concerns
- provide evidence that case management is no longer required and that closure is warranted.
For children and young people in OOHC there are certain legislative requirements for the timing of reviews according to a child or young person’s age and care situation. Section 150 of the Act stipulates that reviews of OOHC placements should occur:
- at four months, if under an interim order of the Children’s Court
- within two months of a final order of the Children’s Court, for a child aged under two, and then every 12 months
- within four months of a final order of the Children’s Court, where the child is aged over two, and then every 12 months
- after the death of a parent or authorised carer
- after an unplanned change of placement.
More frequent reviews can be conducted if necessary.
Case Study No: 5
An immediate case plan review meeting was organised by the Family Support Service caseworker as Sara and the children’s circumstances had changed with Sara resuming her relationship with Paul, whom she had a current ADVO against.
Prior to the meeting the Family Support Service caseworker met with Sara to prepare her for the review and to discuss the safety, welfare and wellbeing of the children. Sara was also encouraged to share her views about any challenges she had encountered with each of the case plan goals.
At the review meeting each worker shared information on the progress of each case plan goal, providing evidence from a range of sources, which included feedback from Sara and her caseworker and the children’s school. Achievements were highlighted and progress of the improved impact on the children’s safety and wellbeing was measured. There was also discussion about the case plan goals that were not met and additional assistance that may be required.
At the meeting the family and the workers reviewed how well the case plan goals were being met. Sara and the children had intermittently attended domestic violence counselling at the community health centre; Sara had been attending the 12 week parenting skills program with the Family Support Service and had engaged well. The Family Support Service attended the family home twice weekly and reported notable improvements within the family home. Suzie was attending the school’s breakfast program regularly and had initially engaged well, however in recent times had some difficulty getting along with other children. Ben was attending the “transition to school” program and it was reported that Ben took some time to settle into the program and while his behaviour had improved there were still some issues that required attention. The ADVO was still active against Paul, however Sara admitted acting contrary to the ADVO by allowing Paul to stay the night 3-4 times per week.
The mix of information shared by participants was used to inform the development of a new case plan, which continued to address the ongoing case plan goals and also responded to the issues that arose out of the review. The main issue of concern arising out of the case review meeting was the safety, welfare and wellbeing of Sara and the children with Paul’s presence in the family home.
A new case plan was agreed to by Sara and the organisations. Each Service provider received a copy of the revised plan that included:
- specific and measurable goals
- timeframes for each goal
- a clear outline of the roles and responsibilities of each service provider
- mechanisms for communication and monitoring the case plan, and
- a date for the next case review.
After the case review meeting, the Family Support Service caseworker consulted her supervisor and re-applied the Mandatory Reporter Guide (MRG), including the information that Paul was frequently spending the night in the family home. The MRG advised that an immediate report to Community Services was warranted. Sara was subsequently informed of this, as were the other organisations.
It is vital that case plan goals are effectively monitored and reviewed to:
- maintain ongoing communication with the child or young person, their family, relevant workers and stakeholders to ensure progress against goals
- record any findings
- consider how to use the information collected
- respond in a timely and appropriate manner to new or emerging issues
- ensure support services are being provided as agreed
- adjust services and supports, when and if required.
To ensure that case plans are reviewed within appropriate timeframes review dates should be identified during the development of the case plan and reminders scheduled to prompt workers.
While monitoring and reviewing a case plan it is vital to remain child-centred. Prompts to assist a worker do this include:
- visiting the family, physically sighting the children and looking for evidence of improvement or deterioration
- ensuring that the child or young person provides feedback
- considering whether the child or young person’s needs or circumstances have changed
- whether the case plan needs to be updated to reflect any changes.
Case transfer is the movement of case management responsibility within an organisation (between offices or regions) and/or from one organisation to another.
A case should only be transferred where the benefits of transferring outweigh the negative consequences of a change in case management, including the involvement of workers/organisations not previously part of the case plan.
There can be many reasons why a case needs to be transferred including:
- the child, young person and their family has moved out of the area
- the child or young person’s needs have changed
- risks have escalated to warrant statutory involvement
- statutory child protection involvement has ended, but other services are still required
- case management goals have changed, which may mean another agency is best placed to case manage
- significant changes in the type or emphasis of service are needed
- final court orders are in place and another organisation will assume case management responsibility.
Transfers should be avoided where possible to minimise unnecessary disruption for children, young people and families and to maintain consistency of case management.
Before case management is transferred it is important that the following occurs:
- stakeholders, including the child or young person and their family, are consulted in a timely way
- the transfer is discussed with the children and family
- the child, young person and family are introduced to the new worker/organisation.
It is also important that the transfer is appropriately monitored.
Case Study No: 6
Peter and Mary have four children aged between two and six years of age. The family is of Aboriginal background from far western NSW and identify as members of the Paakantji tribe.
Community Services began working with the family after a risk of significant harm report to the Child Protection Helpline was made regarding parental substance abuse and domestic violence.
As the report met the criteria for risk of significant harm and the family had a range of serious issues, the case was referred to the local Community Service Centre. The Community Services caseworker was responsible for casework coordination and for culturally appropriate service delivery. An Aboriginal caseworker was consulted during the assessment and to develop the case plan.
The caseworker worked with the family over a period of fourteen months to ensure the safety, welfare and wellbeing of the children. The family then decided to move to Sydney.
The caseworker immediately convened a case planning meeting with all relevant organisations and the family when informed of the proposed move. While the family had been making progress, the caseworker was aware that they required ongoing support and wanted to be sure that the family would continue to connect with essential services. At the meeting the family explained their reasons for the move and acknowledged their ongoing need for support. It was agreed that casework responsibility would be transferred to a Community Services Centre close to their new home.
A timeframe for the transfer was agreed to. It involved the completion of Aboriginal cultural support information and other documentation to assist the new Community Service Centre. All files and documentation were securely delivered via courier to the new office.
The caseworker also telephoned the new Community Services Centre to confirm receipt of the documents and to schedule an appointment between the caseworker and family.
The family’s new caseworker arranged for an Aboriginal caseworker to join that first meeting and assist in developing a revised case plan based on the family’s history and their expected needs for support in their new environment.
There will usually be some point at which a case can be closed.
Case closure is most effective when it occurs as part of a mutually agreed, planned process when case plan goals have been achieved. Where progress has been regularly monitored and reviewed, it is likely that the decision to close will be mutual.
When the organisation with case management responsibility believes it is appropriate to close a case the decision should be made with the child or young person, family and relevant organisations, where possible. This will provide all relevant stakeholders with an opportunity to participate in the decision making process and discuss any measures required as part of case closure.
Where there is not mutual agreement to close, it is important that all stakeholders discuss the issue(s) and identify a solution. This could include a decision to transfer the case to another organisation.
However, case closure by an organisation can also be unplanned and triggered by a range of events, such as a family moving interstate without a forwarding address.
Where there are statutory child protection concerns about a child or young person an interstate alert can be raised by Community Services. An interstate Child Protection Alert applies where serious child protection concerns exist and a child/family’s interstate location is unknown. Under an interstate Child Protection Alert Community Services sends information about the children and their family to other jurisidictions, including information about the concerns, Community Services’ level of involvement and what actions Community Services would like the receiving jurisdiction to undertake. When an interstate Child Protection Alert is received by another jurisdiction it is entered into their client database and if the family is known, or becomes known to that jurisdiction, required assessments and/or interventions will occur.
A review should always be conducted prior to closing a case and a clear record of this process kept.
Case Study No: 7
Nadia is a single mother with three children aged between three and seven. Nadia’s husband recently passed away and since then the family have struggled emotionally and financially. The Education Child Wellbeing Unit (CWU) became aware of the family’s situation when the school Principal reported that Nadia’s eldest child, Rania, told her teacher that her mother had severely physically disciplined her on the weekend.
The CWU assessment officer assisted the Principal to apply the Mandatory Reporter Guide (MRG) and the report was assessed as not reaching the threshold of risk of significant harm and requiring a report to Community Services, but nevertheless required a response. The CWU also checked the WellNet database.
The CWU assessment officer provided the Principal with details of the local area Multicultural Support Service and asked the Principal to speak to Nadia about her daughter and whether any additional supports were required, particularly in view of the recent passing of Nadia’s husband. The assessment officer suggested to the Principal that she seek Nadia’s consent to make a referral to the service. Nadia readily agreed.
The Multicultural Support Service conducted an assessment, supported by an interpreter, which revealed that Nadia may also have underlying mental health issues.
These mental health concerns and Nadia’s parenting capacity were the main issues to be addressed to ensure the safety, welfare and well being of the children. A case plan was developed that included case management by the Multicultural Support Service, a referral to the Transcultural Mental Health Centre for assessment and bereavement counselling for Nadia and the children.
The Multicultural Support Service monitored and reviewed the case plan and the family’s progress and ensured any difficulties were addressed.
Over the following two years, Nadia had regularly attended her Transcultural Mental Health appointments. Her mental health issues had improved and were assessed as manageable. Both children were thriving and engaging well at school. The Multicultural Support worker was only visiting once a month and reported that Nadia was coping well and there were no concerns in the last six months. Nadia had also become involved in a cultural women’s support group.
The Multicultural Support worker recommended to her supervisor that the case could be closed. She discussed this with Nadia and the children, noting that case closure meant that intensive support service would cease, although they could continue to access day-to-day support services. The caseworker also assured Nadia that the Transcultural Mental Health service would continue to support her to manage her mental health issues.
Before getting Nadia’s final agreement to the case closure the caseworker contacted the Transcultural Mental Health service to flag the proposal with them. Following their agreement the caseworker completed the case closure documentation and sent letters to Nadia, the Transcultural Mental Health service and relevant agencies, including the children’s school, confirming that the intensive services would cease.
Case transfer is about a change in the organisation that has case management responsibility. The following points can assist in making the transfer process as smooth as possible for all involved:
- prior to case transfer the organisation with case management responsibility should convene a case management transfer meeting with the organisation that will be assuming case management
- records should be up-to-date and information transferred in a timely fashion
- children, young people and their families should actively participate, as this is fundamental to shared decision-making
- follow-up should occur with the child, young person and their family to monitor the impact of the transfer.
The decision to close a case should ideally be a planned one, reached as a result of careful consideration. Some points to guide the process include:
- reviewing the case to inform the decision
- discussing the case with a colleague, supervisor and organisational partners
- talking through the decision with the child, young person and family to ensure they understand what is about to happen
- ensuring that organisational policies and procedures are adhered to, including record keeping and issuing of correspondence.
Case management in operation
The nature, extent and complexity of the needs of a child, young person and their family and the type of services being provided or that need to be provided will influence whether case management is necessary and who has case management responsibility.
The benefit of case management is that it enables a comprehensive, thorough assessment of the individual, their family, their needs and strengths. Secondly, it provides a framework for responding to identified problems and monitoring progress. This is very important when more than one worker and/or more than one organisation is involved.
At an organisational level collaborative case management can lead to greater efficiency in the use of resources, improved service delivery by the avoidance of duplication and overlap and the clarification of roles and responsibilities. It can also enhance the opportunity for creative solutions.
The NSW Government has established a framework of collective responsibility and this duty to work together is legislated under section 245E of the Act. Prescribed bodies are required to take reasonable steps to coordinate decision making and the delivery of services regarding the safety, welfare or wellbeing of children and young people. A prescribed body is any organisation specified in section 248(B) of the Act and in clause 7 of the Children and Young Persons (Care and Protection) Regulation 2000. Further information about prescribed bodies can be found in the Exchanging Information Relating to Children or Young People in a Child Wellbeing Context chapter.
The provision of universal services can be the responsibility of a government or a non-government organisation. For example, health home visiting is a NSW Health funded service while the local child-care centre is privately owned and operated. Universal services are preventative in nature and designed to avert the development or emergence of problems and issues, they tend to be delivered independently of each other. Generally, case management, or a formal collaborative approach, is not required.
This does not preclude universal service workers from using other collaborative mechanisms, such as unstructured informal communication links between workers or low-key joint working on a case-by-case basis. This informal working arrangement could occur when the issues are not considerable or complex enough to warrant case management.
Early intervention provides vulnerable children, young people and families with services to help prevent the escalation of problems. Early intervention aims to provide support to improve family resilience, minimise future crisis and reduce the incidence of child abuse and neglect.
If the issues faced by a child, young person or their family become more complex and/or more than one organisation is delivering services, case management may be required.
Decisions about case management responsibility should be guided by the circumstances of the case. This includes the nature and extent of the problems faced by the child, young person and their parents, required services and organisational capacity.
It is important to note that identifying who has case management responsibility will not necessarily follow a linear process. For instance, an organisation may develop or be advised of concerns about the safety, welfare or wellbeing of a child or young person. Through information gathering, talking to internal and external colleagues and investigation the true nature and extent of the problems can become apparent. It is only from this point, once the problems are quantified and relevant organisations have considered and discussed the case, that the issue of who has case management responsibility can be resolved.
Not every matter will require collaborative case management and workers should consider whether the circumstances of a particular case warrant adopting a coordinated approach.
Child, Youth and Family Support
The Child, Youth and Family Support early intervention service model (within Community Services) aims to deliver a broader range of less intensive early intervention services to meet the needs of vulnerable children, young people and families who fall below the threshold for statutory child protection intervention. The Child, Youth and Family Support service model is structured to deliver two streams of service provision:
- Child and Family Support, targets families with children aged 0 – 12 years
- Youth and Family Support, targets young people aged 12 - 18 years or families with young people in this age range.
Case management will usually be provided to young people and families who require additional and ongoing support to access appropriate services for an average duration of three months. If there is a need to extend case management for longer a reassessment of need will be undertaken after three months and a new case plan developed.
Brighter Futures is a voluntary program delivered by non-government organisations. The program provides vulnerable families who are expecting a child or have children aged less than nine years with the services to prevent entry or re-entry into the statutory child protection system. The program delivers case management and a range of tailored services including home visiting, child care and parenting programs.
Family Case Management (FCM)
Under Keep Them Safe the NSW Government is piloting an integrated case management response to families who frequently come into contact with multiple government agencies and non-government organisations and show little improvement in their situations. The aims of FCM are to strengthen overall family functioning and reduce the risk of harm to children and young people. There is also a focus on improving agency collaboration so that procedural, policy and system barriers do not prevent frontline staff from effectively helping families.
FCM is running in eight sites in three regions: South West Sydney, South East NSW and Western NSW.
Keep Them Safe Whole Family Teams
The establishment and implementation of the Keep Them Safe Whole Family Teams aims to address the needs of whole families where carers have mental health and/or drug and alcohol problems and parenting difficulties, and there are child protection concerns. The teams will provide specialist comprehensive assessments; case management; and specialist group, family, and individual interventions over a six-month period. In addition, they will coordinate, link, and network with other support services to ensure that clients can be treated in a holistic manner and can continue to receive support following intervention.
The teams are being piloted in four locations:
Further information can be found at Keep Them Safe.
Statutory child protection
In the statutory child protection system, case management is a Community Services function. This is in keeping with the agency’s statutory responsibilities of assessing and investigating ROSH matters to ensure the safety of children and young people.
The Act states that in any action or decision concerning a particular child or young person, the safety, welfare and wellbeing of the child or young person is paramount. While other organisations may take some responsibility, Community Services cannot delegate its accountability for assessment of ROSH.
It should be noted that by virtue of the operation of section 29A of the Act a mandatory reporter is not precluded from responding to the needs of a child or young person, as appropriate to their profession, because they have made a report to the Child Protection Helpline. Organisations should consider the child or young person’s safety, welfare and wellbeing as paramount and continue working with the child, young person and their family, where appropriate.
When a child or young person has been assessed by Community Services as being above the statutory threshold and in need of care and protection, provided that the family is not being referred to a placement prevention service (such as Intensive Family Support or Intensive Family Preservation) or will be placed in OOHC, then case management will be the responsibility of Community Services.
As with non-ROSH cases, while Community Services may have case management responsibility there are other opportunities to work collaboratively so as to benefit the child or young person. This includes referrals and/or requests to other organisations.
Community Services’ early intervention program focuses on families whose needs are complex enough to put them above the statutory threshold and/or who have had previous or ongoing involvement with the statutory child protection system. This is in line with the evaluation results which showed that a Brighter Future type intervention worked effectively with families that had previous contact with the child protection system. Stronger Families provides the same services as Brighter Futures.
Government departments and non-government organisations in receipt of government funding can be requested to provide a service to a child, young person or their family that will promote and safeguard the safety, welfare and well-being of a child or young person (sections 17 and 18 of the Act). The organisation must use its best endeavours to comply. Best endeavours means to ‘make a genuine and considered effort’.
Community Services will make a request for services in writing. Organisations are required to provide written advice of their response including:
- providing information about the service or program that they considered for the family or family member
- what they can actually provide, or alternatively
- reasons for their inability to provide the required service.
Requests will not usually be made as a first-attempt referral. The prerequisite conditions for a section 17 request are that the:
- identified service or program is necessary for the child or young person’s safety, welfare and wellbeing
- requested service or program is run by a government department, agency or a non-government organisation in receipt of government funding
- usual referral channels or referral procedures have not been successful (such efforts may have been made directly by the family themselves or by an officer of Community Services).
Under section 85 the Act the Children’s Court can also request a government department or a funded non-government organisation to provide services to assist in the restoration of children and young people to their families. Best endeavours to comply also apply for these requests.
Community Services is implementing new guidelines to manage the allocation of RoSH, and certain non-RoSH events , within Community Services Centres. The primary aim of the process is to support the effective utilisation of resources by targeting intervention to children and young people who are at the highest ROSH.
A key element on the process is the Interagency Case Discussion Meetings (ICDM). Where Community Services has been unable to allocate a ROSH report; safety and/or risks may still be apparent; the child, young person and/or family are involved with other services and a mandatory reporter has made the report to the Child Protection Helpline Community Services will consider whether an ICDM is required.
The purpose of the ICDM is to enable organisations supporting the family to share information and expertise. It will also enable identification and discussion of appropriate actions or services that may be implemented to reduce risk to the child or young person.
If Community Services identifies that an ICDM would be beneficial, the mandatory reporter and other relevant services will be invited to participate.
If Community Services determines that a child or young person is at ROSH and is at risk of being placed in OOHC then the family may be referred to an Intensive Family Support Service (IFS) or Intensive Family Preservation Service (IFP), provided they meet the eligibility criteria and the service provider has the capacity to accept the referral.
IFS differs from IFP in terms of the service delivery intensity and target group, with the former focusing on families who have children at ROSH, but are not at imminent risk of removal. Whereas IFP targets families where the risk of placement in OOHC is imminent.
Case management responsibility will transfer from Community Services to an IFS or IFP, in some cases, at or after referral. Case management will transfer if: \
- Community Services child protection action is complete and there is no court action
- other long-term orders, such as a supervision order which places the child or young person under the Director-General’s supervision, are in place
- joint case planning is done with the service before case transfer
- there is an express agreement in the case plan that if the risk for the children or young people in the family becomes unacceptable, the case will be referred back to Community Services.
Where a service has case management responsibility each family will have an assigned case manager to plan, coordinate and implement the best service mix.
Case management in both IFS and IFP is time limited and goal directed. Both IFS and IFP will supply direct services, as well as coordinate and make active referrals to other service providers and appropriate community-based programs as necessary
Intensive Family Based Services (IFBS) are a culturally relevant, time-limited, home based voluntary program for Aboriginal families in crisis whose children are either at risk of entering OOHC placement due to safety and protection concerns or whose children have already been placed in OOHC with a restoration plan in place. IFBS work intensively with families for a period of up to three months. Community Services refers eligible families to an IFBS and retains case management responsibility, with specific tasks contracted to the IFBS.
For children and young people under a care order or living in OOHC, case management may be with Community Services or a designated agency (which is a government department or other organisation that is accredited to arrange OOHC) or be a joint responsibility.
For OOHC, case management will transfer from Community Services to a non-government (contracted) agency in the following circumstances:
- Community Services child protection action is complete and Community Services is not undertaking court action
- final Children’s Court Orders for sole or shared Parental Responsibility to the Minister are in place
- final Children’s Court Orders for restoration are in place
- other long term orders, such as a Supervision Order, are in place.
Case management will not transfer in the cases where the child or young person satisfies all of the following criteria:
- has significantly complex needs, and
- is assessed as at high risk of immediate or serious harm, and
- case management requires high level collaboration from other government agencies that is unable to be achieved by non-government organisations.
Transfer of OOHC to the non-government sector
Keep Them Safe sets out the NSW Government’s policy to transfer the majority of OOHC placements and case management to the non-government sector. This is a substantial reform and a transition plan is being finalised by Community Services in order to commence the transfer.
The following points suggest some practical ways in which organisations can work collaboratively:
- identify and establish formal and informal communication networks with relevant organisations and build partnerships
- maintain current knowledge about local organisations
- use the information exchange provisions to gather relevant information relating to a child or young person’s safety, welfare or wellbeing
- request the involvement of organisations where a need to work collaboratively has been identified
- discuss and reach agreement on how the collaborative arrangement will work, including the child, young person and their family
- nominate a ‘key worker and/or organisation’ to lead or oversee the collaborative arrangement, where required
- formalise collaborative relationships where necessary through policies, protocols or agreements
- establish mechanisms to resolve differences or disputes, such as the model to resolve any interagency differences.
Arney, F. & Scott, D. (eds). 2010. Working with Vulnerable Families, Melbourne: Cambridge University Press.
Cousins, C. & Toussaint, S. “You wrote what?!..dangers and dilemmas in record keeping”, in Developing Practice, 10: Winter 2004, 38-45.
Moore, E. (ed) (2009), Case Management for Community Practice, Melbourne: Oxford University Press.
NSW Department of Human Services, Community Services. 2010. Research to Practice Note: Interagency Collaboration.
Summers, N. (2009), Fundamentals of Case Management Practice, 3rd ed, Belmont California: Brooks / Cole.
Tomison, AM. & Stanley, J. 2001, Strategic Directions in Child Protection: Informing Policy and Practice. Brief No. 3 Social welfare framework: Models of collaborative service delivery in child protection. Unpublished report for the South Australian Department of Human Services.
Walker, S., Sherrings, J., Cleaver, H. 2003, ‘Write Enough’. UK Department of Health. http://www.writeenough.org.uk