2.15 Developing a Service Plan & Monitoring

When we are looking a Developing a Service Plan and then monitoring how the client is doing there are many different systems to doing this.  Depending on the agency we work in as well as the population your agency serves these plans may have different names.  They could be: service plans, treatment plans, goal pans, care plans or Healthy Living Plans.

A service plan contains broad, general goals for the case management unit to follow in regard to that specific client.  Referral will then happen to those in the agency or outside the agency that would help the person reach those goals.

Developing a Service Plan at the Case Management Unit

When developing the Service Plan it is important to take into consideration all information that is shared and documented.  It is considered an important piece to include the Client and their family as todays service plans take into consideration the family unit, as well as the environment that the Client is returning to.

There is an expectation that all agencies engage both the client and their family (with permission from the client) when this inclusion is appropriate.  This allows for a stronger success rate when the family unit is supported.

It is important to document all information that is gathered when doing an Assessment Interview.  The Assessment Form will show many different types of information that can be asked and information gathered.  It is also important to correctly document and record all necessary information as it assists in giving a clear picture of the client, the issues, the challenges and critical information that we need to be aware of when creating a service plan.

Implement Documentation and Recording of Important information

An important piece to remember is that if it isn’t documented it is like it never happened.  Verbal conversation isn’t enough, it must be documented that the conversation took place.

In some agencies it must be documented for funding purposes.  When working in supportive housing, a set # of  hours had to be documented as face to face time with our clients.  Therefore documentation was critical.  This is not an option, documentation is critical for legal purposes as well as making sure that appropriate care is being given to our clients.

Monitoring client, agencies and service is also another component of what documentation and recording is being done appropriately.

Prepare a Treatment Plan

A lot of agencies have clinical meetings or a meeting of staff where discussions are around clients and their treatment plans and needs.  It is important to have a provisional plan for your client when you attend this meeting.

Treatment plans are a written document that includes:

• identifies the client’s most important goals for treatment
• describes measurable, time sensitive steps toward achieving those goals
• time-limited and reflects a mutually agreed upon, written agreement, between the clinician and the client
• a bridge between assessment and treatment
• is individualized

Why are Treatment Plans Important?

• gives a roadmap of the recovery process
• provides structure – very important (client’s will have experienced some chaos)
• outcome driven – focus on treatment
• individualized treatment plan will be reviewed, approved and signed by counsellor and client
• treatment plans will include progress notes, addressed whats been accomplished, showing goals and objectives and progress (and occasionally challenges)

Identifying Challenges / Problems

• important to show challenges that the client has had to create solutions
• note most significant issues presenting (ADHD, substance use etc)
• challenges that are most challenging
• treatment plans will address a selected # of challenges, the direction and focus
• diagnosis / challenges

Creating a Goal

• brief statement of something you’d like to change
• tied to the assessment
• broad goals in order to replace dysfunctional behaviours with healthier ones (longer term)
• at least 1 goal to relate to the substance abuse
  • attend meetings
  • meeting with a counsellor

Creating objectives

• action client will do to meet the goals (skill development)
• objectives (visible) in measurable behavioural language – clear
• stated clearly
• objectives are skill developed by client
• target date attached for completion

Using SMART Goals

• SPECIFIC
• MEASURABLE
• ATTAINABLE
• RELEVANT
• TIME LIMITED 

Learnstorm Growth Mindset:  How to write a SMART goal by Khan Academy.

Treatment Plan Updates / Progress Views

These are important and should be completed ongoing.  It is important to record it so that it shows progress and keeps client motivated

MONITORING

Monitoring is one of the main case management tasks when working with a client/family.  Not only do you monitor the client/family but also the agencies that you made referrals to for several reasons.  One of the requirements is documentation for your agency to get reimbursement for their time, as well as ongoing contact with the client/family offers reassurance and support.

It also offers an opportunity to trouble shoot before a situation becomes too large and perhaps a hospitalization or critical situation can be avoided.

As one of the pieces we do is developing goals and objectives are personal to the client/family that is supported so if its domestic violence or health issues then it is relevant to make sure that we are making sure that the goals are being met.

The function of Monitoring and adapting a treatment plan for client/ family

Monitoring is two-fold.  It confirms that the client is actually active in the process and are accessing the services and plans that were made for them.  It also gives an opportunity to see if the service that was referred and is supposedly being used is actually the best fit for the client.

If there’s a disconnect or crisis that is going on, again it is easier to know at an earlier stage than when it has escalated into a larger problem.  There is also an accountability piece for the agency as well as for the funder.  If money is being spent it is important to make sure it is being spent wisely and therefore accountability is vitally important.

Advocate on behalf of a client/family on micro level, meso and macro level

Advocating on behalf of a client/family is critically important, especially on the micro level (client’s), meso level (context surrounding the person) and macro (larger society’s characteristics) specially to see how it is working for them.

If the client/family is unwilling or unable to participate or the agency is unwilling or unable to give the services to the client/family is it important to look into it and possibly change the agency to another one that could deliver the service.

If you can work with the agency that provides the service you require that is great, but if not and you need to look at another agency then that might be what is needed.

We have looked at some of the pieces that will arise when monitoring services and following the client, we will be able to understand the many different situations we may encounter and it is important to equip ourselves and know what to do in different situations arise. The clients that we will work with have come to our agency for assistance and we can better support them if we understand best practices in all areas and continue to build on our relationships with other agencies.