Follow a clear case management process from intake to review and transition, with the person’s goals and history kept in view.
Case management is a collaborative process for understanding a person’s needs and goals, planning support, coordinating services and reviewing progress. The process should help the person navigate support rather than require them to rebuild their story at every handoff.
Stages and professional requirements differ by setting. This guide describes a general service workflow, not a clinical protocol. The NASW practice standards emphasize collaboration, assessment, planning, monitoring and documentation in social work case management.
| Stage | Purpose | Useful record |
|---|---|---|
| 1. Intake and engagement | Understand the request and explain the service. | Referral, eligibility and agreed contact details. |
| 2. Assessment | Understand goals, strengths, needs and barriers. | The person’s account and relevant evidence. |
| 3. Planning | Agree priorities and responsibilities. | Goals, actions, owners and review dates. |
| 4. Coordination | Connect the person with appropriate support. | Referral status and agreed information sharing. |
| 5. Monitoring and review | Check progress and adjust the plan. | Updates, unresolved barriers and decisions. |
| 6. Transition or closure | Agree what happens next. | A handoff or closure summary and re-entry information. |
Explain what the service can and cannot do, what information is needed and how it will be used. Confirm eligibility without asking people to repeat information already available and appropriate to reuse.
Record the presenting request in the person’s words where possible. Distinguish a referral source’s description from the person’s own account. Identify urgent concerns using the organization’s established procedures and qualified staff.
Explore strengths, preferences, goals and barriers alongside needs. Relevant documents can support the conversation, but an uploaded file is not a completed assessment. Review its source, date and relevance.
Avoid collecting sensitive detail merely because the form has a field for it. Record uncertainty and disagreements respectfully. The assessment should support a shared plan, not reduce the person to a label.
Agree a manageable set of actions with the person. Each action needs an owner and review point. A referral is not complete simply because an email was sent; check whether the receiving service accepted it and whether the person could access it.
| Goal | Action | Owner | Review |
|---|---|---|---|
| Prepare for suitable work | Arrange an agreed skills assessment. | Participant and adviser. | At the next scheduled appointment. |
| Remove an access barrier | Check available transport support. | Named coordinator. | Before the assessment date. |
| Continue support | Confirm the receiving service and contact. | Current and receiving staff. | At handoff. |
At review, compare the current situation with the agreed goals. Ask what helped, what did not happen and what has changed in the person’s circumstances. A missed appointment may reflect an access barrier; it should not automatically be interpreted as lack of motivation.
Keep notes dated and distinguish observations, the person’s statements and professional interpretation. If the plan changes, record why and what happens next.
In an illustrative workforce service, a participant moves from an intake adviser to a placement coordinator. A useful handoff includes the person’s goal, assessment date, agreed actions, current barriers and any restrictions on sharing information.
The receiving coordinator should be able to see what is current and what is historical. They should not need to infer the plan from a folder of undated attachments. Confirm responsibility for outstanding actions with the person and receiving team.
Review what was achieved, what remains unresolved and what support is available next. Explain how the person can return or seek help if circumstances change. Closure should follow the service’s policy and professional obligations, not merely an inactive record.
A transition summary should be proportionate and accessible to its intended reader. Share only what is appropriate for the agreed purpose.
AI may assist with organizing or summarizing records, but important judgments require qualified review. A generated summary should link back to the evidence and must not replace safeguarding, clinical or professional procedures. For the related workflow, see case management.
No. Organizations and professional frameworks group the work differently. The important issue is whether assessment, planning, coordination, review and transition are covered appropriately.
A note records an interaction or observation. A plan sets goals, actions, responsibilities and review points. Notes should inform the current plan.
No. Information should be relevant to the service purpose and the person’s situation. Avoid unnecessary collection.
It may support organization and review, but it should not replace accountable professional judgment or established decision procedures.
