Complex Cases Often Fail in the Handover, Not the Plan

Often, complex cases fail in the handover, not in the plan. A one-page case brief can transform a complex plan into support that will be effective on any day.

Despite a participant having a thoughtful assessment, sensible goals and agreed service mix, the first worker still arrives without the information to support the participant well.

Typically, complex plans are distributed over multiple reports and systems. A snapshot of the person, what their priorities are, the identified risks, how they communicate and the escalation pathway, rather than a folder that they cannot read during a shift.

Why this matters for case managers

In the case of case managers, value is often being generated between the formal decisions; when it's a handover, a provider change, or when a daily issue comes up and the agreed upon arrangement is not yet working. The best answer is one that includes the direction of the participant and brief notes, as well as named tasks and a realistic check point. This helps to minimise unnecessary coordination friction, but maintains professional and provider accountability.

What better coordination looks like

A valuable one-page brief helps to bring professional planning into the realm of what happens at home and in the community. It is written with the person, uses plain language, separates preferences from risks and makes ownership visible.

Start with the person

Document the person's preferred name, the issue(s) of the day, communication preferences, and desired shift from a person's perspective.

Name the essential actions

List only the routines, safeguards and outcomes that all workers need to know and provide a link to detailed plans when necessary.

Make escalation unambiguous

Indicate what to document and who to call and what changes need professional or emergency attention.

Make the change last

Useful change is specific enough to practise and small enough to review. Decide who will take the first step and decide where and when the decision will be documented, and when the individual will be asked if this helped. If the approach requires multiple services, then review the roles individually, and not in the meeting assuming that agreement in the meeting is agreement in “action”. Keep what is effective, change what is not and eliminate temporary strategies that no longer achieve the desired results.

Questions for the next review

What would “start with the person” look like from the person's point of view?

What is assumed and what is to be expected?

What will happen to the person and group that will signify whether this strategy is successful or not?

Keep the boundary clear

A brief should not be a substitute for a clinical, behaviour support, medication or emergency plan. It is designed to provide orientation and coordination. Consent, privacy and document control remain and the participant must be aware of who will have access to information.

A practical example

One case manager was able to reduce repeated calls to reorient, co-designing a brief with a participant who was supported by three providers. The morning priorities, preferred prompts and pathway of contact could be viewed at a glance by the workers. The plans that were in place continued to be in effect, but the handover became regular.