Chapter 9 Service Coordination
Following plan development, case managers have two responsibilities. One is to
provide direct services; a second is to coordinate services supplied by other
staff, other agencies, or both. This chapter focuses on the second, service
coordination, and related skills. These include making referrals, monitoring
service delivery, working with other professionals, being an advocate, and
teaming with others. This chapter provides opportunities for you to develop your
own skills in these areas.
Pretest
After you read Chapter 9 in Generalist Case Management, answer the following
questions and complete the items.
1. List three advantages of service coordination.

2. How can a client participate in service coordination?

3. Define “referral.”

4. Distinguish between coordinating services and monitoring services.

5. List the guidelines that lead to successful advocacy.

6. How do the following teams differ? Treatment team:
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Departmental team:
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Interdisciplinary team:
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Team with family and friends as members:
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Chapter Summary
Although case managers have been providers of direct services in the past, one
of the most important responsibilities of case managers today is the
coordination of services. Rarely can one person or one agency meet all of the
needs of a client. Because of this, the case manager will locate needed
resources in the community, arrange for the client to use them, and support the
client in using them. Once the case manager and client have agreed upon a plan,
then the case manager will locate appropriate resources and make referrals to
service providers. The case manager is responsible for documenting throughout
the process and should also monitor service delivery to ensure that the client's
needs are being met.
While coordinating services, the case manager maintains working relationships
with other professionals. Good communication skills are vital during this
process. Maintaining appropriate, professional communication with service
providers will help meet the needs of the client and any future clients that
might require the services of that professional. Often, clients cannot
articulate what they need and do not understand what choices are available to
them. Case managers might find themselves assuming the role of advocate in their
attempts to locate and acquire services for their clients. In this role, the
case manager should keep in mind the needs of the client and the other parties
involved and develop a clear plan for the client. Because a number of

professionals often provide services for a client, teamwork is common. Using
teams improves the delivery of services for clients with multiple needs and
increases the number of available resources.
Exercise 1: Janis Jones
Review the case of Janis Jones in Exercise 2 of Chapter 8. In Chapter 8, you
identified Janis's problems, encouraged her participation in plan development,
and anticipated barriers to service delivery.
Goal 1 of the plan follows. Review it and respond to the questions that
follow it.
THE PLAN

1. How will

2. How will

3. How will

Goal:

Objectives:

4. Describe

5. Describe

6. Will you

Exercise 2:

you encourage Janis's participation in reaching the goal?
you make the referrals? Do you anticipate any barriers? Explain.
you monitor service provision? What is YOUR plan?

the criteria you will use for the evaluation of service provision.
a situation where you will advocate for Janis.
be a broker or a mobilizer? Explain.
Working with Other Professionals

To meet Goal 1, you as the case manager will work with other professionals,
including a psychologist (psychological evaluation), social worker (social
history), physician (physical examination), and principals, school counselors,
and teachers (educational information).
1. What will you tell them about Janis?

2. What questions do you have for each professional to guide his or her
evaluation of Janis or your data collection? Psychologist:
__________________________________________________________________

Social Worker: _________________________________________________________________

Physician: _____________________________________________________________________

Principal: _____________________________________________________________________

School Counselor: ______________________________________________________________

Teachers: ______________________________________________________________________

Exercise 3: Making a Referral
1. Read the case study about an Australian veteran.
Jason's mental health problems include posttraumatic stress disorder, major
depressive episode, panic attacks and social anxiety disorder.
Jason is a 34-year-old, unemployed, separated man presenting with a brief
discharge summary from the local emergency department. He was discharged this
morning after being observed overnight following a potentially lethal overdose

of painkillers and alcohol. He had refused to wait to be seen by the psychiatric
triage service. He lives with his parents who took him to see their general
medical practitioner.
Jason was discharged from the army four months ago after having spent three
months in a rehabilitation unit. He had been an elite infantry soldier and had
served for six months in Afghanistan. He had been involved in covert operations
and described about six intense episodes of contact with Taliban fighters. On
his return to Australia, his performance and conduct had deteriorated and he had
been disciplined for alcohol-related misconduct. He faced immediate dismissal
from the army after being caught smoking cannabis, but his service record and
supportive commanding officer meant that he was given a second chance via the
rehabilitation unit. Marked problems of anxiety and depression became apparent,
leading to a medical discharge.
Jason is visibly depressed and distressed. He reports chronic insomnia,
weight loss (10 kg in the past 6 months), lack of motivation, periods of
agitation, and active suicidal ideation. He provides an assurance that he would
not try to harm himself again and promises to stay in sight of his parents.
Further questioning reveals a severe syndrome of posttraumatic stress disorder
(PTSD), with daily distressing memories, nightmares, marked distress with
reminders, anger bordering on rage, use of alcohol to avoid racing thoughts and
memories of Afghanistan, “emotional shutdown,” poor concentration, and marked
hyper vigilance. His reactions to triggers are consistent with full-blown panic
attacks. He has been binge drinking, consuming almost a bottle of spirits in a
single session.
Jason is suspicious of authority figures and reluctantly agrees to return the
next day for a longer appointment. The following day, his presentation remains
that of severe major depression and his suicidal ideation remains active with
well-developed plans. Jason is referred that day for inpatient mental health
treatment. He is discharged four weeks later, much improved on a regimen of
antidepressant medication. He has been linked in with the VVCS (Veterans and
Veterans Families Counselling Service) for individual counselling and referred
to the PTSD program [funded by DVA (Department of Veterans' Affairs)] at a local
hospital for assessment and treatment of PTSD.
Source: Mental Health Advice Book. (n.d.). Australian Government, Office of
Veteran's Affairs. Retrieved from http://at-ease.dva.gov.au/www/html/276-254jason-recent-veteran.asp?intSiteID=l
2. Using the information provided by Jason's case, identify two problems that
Jason is experiencing.

3. Assume that your job as a case manager is to provide Jason the services he
needs through referral. Also assume that Jason lives in the city or town in
which you currently reside. Using the telephone book, the web, a directory of
social services, and colleagues and fellow students, identify at least one
agency that might provide the services Jason needs for each problem you listed
in item 2. Find out the following information about the agency.
a. What is the purpose of the agency?

b. What services does the agency provide?

c. What is the target population?

d. What are the eligibility criteria to receive services?

e. What process is available for making referrals?