Six Services, One Participant, No Shared Picture

Don't let drift occur between providers, always make outcomes, roles and communications clear.

The participant may feel that there are redundant tasks, follow-up was not done, and conflicting advice was given, despite being surrounded by services.

Each provider may be executing its own portion right, but the group is operating out of the participant's focus. The gap is between organisations where ownership is not apparent.

Why this matters for case managers

For case managers, the value is mostly generated between formal decisions, such as in a handover, between a change of provider, or when an everyday problem arises and it's clear that the agreed arrangement isn't yet successful. The best answer includes a brief note and clear assignment of responsibilities and a realistic review date. This helps minimise unnecessary noise in coordination and ensures the correct focus on accountability for professionals and providers.

What better coordination looks like

Case managers need not replace other professionals from the team to develop a shared picture of the case. A short outcomes-and-roles matrix is better than another long meeting.

Anchor to outcomes

Make a note of what the participant's current results are in plain terms and indicate the services that lead to these results.

Make interfaces visible

Note handovers, interdependencies and instances where two agencies must work closely together with permission.

Make interfaces visible

Short reviews, discussing missed, duplicated activity, not repeating what is working.

Make the change last

A useful change is specific enough to practise, and small enough to review. Decide who will take the first step, record where it will be documented and when the person will be asked if it was helpful. For multi-service approaches, ensure that each service is agreed upon individually, not during a meeting. Keep what is working, tweak what doesn't, and eliminate what is temporary that is not achieving the desired results.

Questions for the next review

How would anchoring to outcomes look from that person's perspective?

Which is fixed, which is assumption or request?

What change is observable that will be evidence to the person and team that this is working?

Keep the boundary clear

Coordination is not a form of authority over another provider. Reflecting the scope, profession and contractual obligations of each service, and the participant's option to share information, each service is held accountable from their respective perspective.

A practical example

In one case, both a therapist and a support worker each assumed the other was running a community-access routine. The gap was revealed by a simple matrix. The approach was defined by the therapist and practised by the worker in everyday situations and monitored by the case manager to see if it was beneficial.