Case Management Framework 2020 - Safety Family Services

1. Introduction

In March 2019, the State Government introduced a new Child and Family Support System strategy that is committed to achieving better health, learning, wellbeing and safety outcomes for children and their families.

Safer Family Services (SFS) will provide help and support to work with children and families at risk of harm, neglect and family violence, by deliberately and strongly intervening to disrupt the patterns of intergenerational trauma, and increase the number of children able to be cared for safely in their homes, connected to culture and community. This is particularly relevant for children and families with multiple and complex needs.

SFS will work with adults who care for children.

While there are several services working toward keeping children safe in their homes, evidence suggests that these services are not working in a connected way (Early Intervention Research Directorate, 2019).

Safer Family Services aims to reduce barriers for children and their families to gain access to timely and targeted services before additional trauma and statutory intervention ensues. Safer Family Services will work in connection with government, non-government agencies and communities to put (at risk) children first, by listening to children and keeping their families strong and well supported.

Article 12 of the UN Convention on the Rights of the Child (1989) advocates for the rights of children and young people to have their voices heard and due weight be given in decisions that impact their lives.

Safer Family Services is committed to providing services that are inclusive of the child’s voice, and do not position children as passive recipients of services. Ensuring authentic and meaningful engagement will be in the context of child development timeframes in childhood and adolescence. Respecting and understanding the fundamental right of children to be safe and connected to culture and family will be at the core of service engagement.

Aboriginal children and young people are overrepresented in every stage of the child protection system, due to a history of injustice, dispossession and the effects of intergenerational trauma. Aboriginal children are ten times more likely to be removed from their family environments than non-Aboriginal children (Australia Institute of Health and Welfare, 2016).

The South Australian inaugural Commissioner for Aboriginal Children and Young People has stated “Aboriginal children need our culture, and our culture needs Aboriginal children” (Lawrie, 2019).

Safer Family Services is committed to working restoratively, building on the resilience and strengths of Aboriginal people, working with, listening to, hearing and acknowledging cultural identity, translating this into practice.

Engaging with families with multiple and complex needs, in the best interest of the child, often means working within an environment that is dominated by fear and anxiety. Assertive engagement and relationship-based case management will be the approach used to deliver support.

For Aboriginal children and families, assertive engagement will be adapted in culturally responsive ways; this may include practitioners engaging with Aboriginal Elders to assist in approaching family members and working in flexible ways to build rapport with children and families.

In addition, by keeping children at the centre of our intervention, we will work collaboratively with adult focused services to ensure that, when they are supporting adults in families, they are mindful of children’s needs (as a priority) to be safely cared for within that family.

The Case Management Framework has been developed to bridge the gap between research and practice. While services within Safer Family Services will have a particular focus on specific phases across the lifespan of the child, the intention of this document is to bring together a Case Management Framework that focuses our attention on the child or young person being cared for safely within their family, and deliver consistent and quality case management practice across Safer Family Services.

2. Explaining Child Protection in the South Australian context

In South Australia, the 2016 Child Protection System Royal Commission found that one in four children are reported to the Child Protection authorities by age ten (EIRD, 2019:2).

The prevalence of child protection is a national concern, with statutory systems across the country at crisis point.

Our role in Safer Family Services (SFS) is to stem the flow toward the statutory child protection system by preventing and reducing abuse and neglect and responding to children and their families earlier.

SFS will work closely, respectfully and with cultural humility with our children, families and other service partners, ensuring connectivity in service responses, when and where they are needed.

3. Our Vision

Child and Family Support System

South Australian families can access high quality, evidence-informed services that enable children to remain safely at home, in community and culture.

4. Acknowledgement of Aboriginal Peoples of South Australia

Safer Family Services (SFS) acknowledges the diverse Aboriginal peoples of South Australia and this Case Management Framework is a guide, by way of prompts, for Aboriginal and non-Aboriginal practitioners to work alongside diverse Aboriginal communities, in keeping children connected to culture, healthy and safe.

Researchers have dated Aboriginal culture as being over 400,000 years old, with Aboriginal people most likely the oldest group in the world that can be linked to one particular place (Creative Spirits website, 2019). Like all other cultures, Aboriginal cultures are continuously interpreted and adapted according to the person or community, however there are common threads and beliefs that continue to be shared amongst Aboriginal people today. There is not one service response appropriate for all Aboriginal peoples; the diversity of nations must be acknowledged, and cultural responsiveness includes building SFS practices that are flexible and able to adapt to meet the needs of the child, family and community.

“Culture plays a key role in the child’s development, identity and self-esteem, and contributes to the overall well-being of the child” ~ Secretariat of National and Aboriginal and Islander Child Care (SNAICC) website, 2019.

Given that the impact of trans-generational trauma, inter-generational trauma and toxic stress is as prevalent today as ever, it is crucial that we adopt respect for and humility towards understanding Aboriginal culture, being mindful of Australia’s colonisation history, dispossession, genocide, the Stolen Generation and historical practices such as segregation and assimilation.

Children respond differently to the trauma they have been exposed to. Aboriginal children can be exposed to trauma daily including by ‘…their exposure to trans-generational trauma and/or intergenerational trauma within their family and community. Living with people experiencing trauma can also trigger high levels of stress in children’ (SNAICC, 2019).

As a system of service responses, SFS acknowledges white privilege, both societal (historical and current) and systemic (understanding how systems confer dominance on a racial group), and how this impact on our engagement with Aboriginal children, families and communities, and more generally on case management practices.

Central to identity is culture. It defines how we raise our children, how we grieve or celebrate, how we interact with others and our environment. Aboriginal child rearing practices and kinship arrangements are central to Aboriginal culture.

“Child rearing…is literally a family and community concern and is not confined solely to the parents of the child” ~ SNAICC website, 2019.

While the mother is the main carer for children, aunties, uncles, cousins and older siblings also have a role to play. Extended family and community play a crucial role and are a protective factor for Aboriginal children. As children get older, their peer group also becomes an important part of their learning. Grandparents, like parents, are very important in the life of Aboriginal children; they also teach children to ‘look up to’ Elders with respect. Grandparents are a protector for children and have significant authority; alongside their parents, they teach the children Aboriginal culture values and beliefs (SNAICC, 2019).

Since colonisation, the survival of Aboriginal nations, in the face of extreme adversity, is testament to the resilience, healing, hope and strength in identity, culture and traditions of Aboriginal nations. Aboriginal people are willing to be open and forgive.

The hope and safety of all children, being cared for by family and connected to culture and community, is a guiding and foundational value on which the Safer Family Services service system is built.

5. Aboriginal system design criteria

A system…

• where Aboriginal and Torres Strait Islander children are front and centre and that is family focused: building a system that ensures the rights of children to safety in protection, meeting families where they are with flexibility and choice
• that reflects Aboriginal and Torres Strait Islander cultural strengths: in all ways, whether through words or artwork, approaches to healing, being, thinking seeing or doing
• that reflects Aboriginal and Torres Strait Islander’s right to self-determination: that supports ‘our people looking after our own people’ and our people supporting one another through building on Aboriginal and Torres Strait Islander strengths and leadership in all its forms
• that reflects the truth of our shared histories, the hurts, the strengths and the healing: through genuinely acknowledging the ongoing consequences of colonisation and the systemic barriers placed in front of Aboriginal and Torres Strait Islander peoples in achieving true self determination with skilled Allies who are committed to changing this.

6. Underpinning values

The Case Management Framework is underpinned by the values that are guided by the United Nations Convention on the Rights of the Child and outlined in ‘Protecting Children is Everyone’s Business, A National Framework for Protecting Australia’s Children 2009–2020’ (COAG, 2009).

• All children have a right to grow up in an environment free from neglect and abuse. Their best interests are paramount in all decisions affecting them.
• Improving the safety and wellbeing of children is a national priority.
• The safety and wellbeing of children is primarily the responsibility of their families, who should be supported by their communities and governments.
• Australian society values, supports and works in partnership with parents, families and others in fulfilling their caring responsibilities for children.
• Children and their families have a right to participate in decisions affecting them.
• Policies and interventions are evidence informed.
• Children’s rights are upheld by systems and institutions.

7. Defining case management

The Case Management Society of Australia (2009) defines case management as “a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s holistic needs through communication and available resources to promote quality cost-effective outcomes”.

Gronda (2009:8) found that successful case management support was characterised by a persistent, reliable, intimate and respectful relationship and involved comprehensive practical support.

8. Principles of the case management framework

Child-centred

Places the person (for SFS, the ‘child’) at the centre of the service response to ensure it is designed to meet individual needs. Children and their families are actively involved in developing their case plans and identifying the service responses required.

Proactive

Prioritise acting in advance to ensure early identification of needs, risks and potential barriers, rather than focussing on reactive responses.

Strengths-based

Identifies and builds on child, family and community capacities including coping mechanisms, resilience and support systems.

Logical

The process of case management is a step-by-step structured approach which is reasonable and considered.

Partnership

Successful partnerships benefit the child and family, through clarity of purpose, good case management leadership, respectful relationships, commitment to collaboration and participation, and a sensitive approach.

Systemic

Makes links to the broader human service system, keeping the ‘big picture’ in mind to maximise child, family and community outcomes.

Outcomes-driven

The work is focused on outcomes and achieving client goals through monitoring, reviewing and accountability.

Culturally responsive

An inclusive approach that is respectful and relevant to the child and family and their cultural identity. Culture refers to a range of personal and community factors including race and/or ethnicity, geography, identity, age, ability, gender, sexuality, family, spiritual beliefs, language, history and economic status.

A cultural response will be integrated into assessment and planning including cultural consultation with Community Elders or Aboriginal specialist practitioners, and consideration of Aboriginal nations will be integral in working to keep Aboriginal children safe and connected to family and culture.

Holistic

The process of considering all factors relating to a child’s wellbeing including (but not limited to), psychological, physical, cultural and social.

Dynamic

Revision of goals and outcomes are undertaken throughout the process of case management allowing responsiveness to the individual’s changing circumstances and progression through case plan objectives. Knowledge gained by working with clients and service systems is used to advocate at both individual and system levels.

9. The case management framework

The case management framework outlines six key stages of service delivery in the case management model.

The process of case management is dynamic, and clients may move through or exit at various stages of the framework depending on presenting need. Specific work practices link to each individual stage.

Supporting families to safely care for their children may require support from multiple agencies, and across several disciplines, in order to address their needs and vulnerabilities and build on family strengths. The focus remains on ensuring that the right supports at the right time can reduce the effects of trauma and harm, keeping children connected safely with their families and lessening the demand on the child protection system.

The focus of engagement when working with families to safely care for their children will include:

• identification, assessment and mitigation of risk
• children’s wellbeing, including safety and strengthening family wellbeing
• respect for diversity, connection to culture and genuine partnership (inclusive of consultation with Aboriginal workers when working with Aboriginal families)
• access to support and services to reduce isolation and increase connection
• enhancing outcomes by collaboratively working with partners and sharing knowledge
• building a culture that is reflective and continually developing, with practitioners who are confident in their practice wisdom
• practice wisdom is supported by evidence-informed approaches and tools, and is focused on outcomes for children, their families and their communities.

The need for culturally appropriate case management interventions which provide sensitive and adequate support for Aboriginal children and their families who are risk of statutory intervention is considered throughout the framework.

Practice point: case management

Case management can be brief and intense, or delivered over a longer period of time. The case management process is dynamic and not always linear, and stages of the framework can happen simultaneously. The process of case management should be seamless for children and their families, with the quality of interaction, not quantity, being the focus of engagement.

Six key stages of service delivery

• Intake
• Assessment
• Case planning
• Implementation of the case plan
• Monitoring
• Evaluation, transition or exit

Intake

Key outcomes

• current child risk and safety issues identified
• historical child protection concerns identified
• family strengths and support identified
• eligibility determined
• provide client or service referral information
• identify agencies involved with client

Referrals to Safer Family Services (SFS) are accepted from a variety of sources and, where systems enable, are triaged by the local line manager. The main purpose of the triage process within the SFS context is for the local line manager to assess all information accessible and consider whether the program will be able to provide support given the following elements:

• child and family’s level of risk / complexity
• urgency of response required and capacity to respond
• are existing supports and services in place
• historical and current concerns of child abuse and neglect (including family violence) and including outcomes from service interventions.

Each of these must be considered separately in order to make safe and appropriate decisions. SFS does not have waiting lists for children and families at risk. If a child and family are not allocated a service due to eligibility or capacity to respond, then an alternative response will be nominated to the referrer within five working days of request being received.

Client engagement

Respect, compassion, a non-judgmental approach and persistence underpins engagement. Work with the client in discussing their needs; recognise and acknowledge the strengths they bring to the engagement process.

Wise use of authority is required, including being as clear as possible about non-negotiables. Ensure transparency early in the process (first meeting) regarding information sharing, confidentiality and obtaining consents wherever possible and practical to do so.

Consider the historical practices, intergenerational trauma, experiences of racism and discrimination that may cause an Aboriginal client to possibly resist involvement for fear of statutory intervention. Consult with Aboriginal workers to ensure discussions are conducted in a culturally safe and responsive way.

Assertive engagement and trauma informed practices will be used to engage children, families and communities.

Client self-referral provides a strong platform to commence building rapport with the client. Meaningful engagement is supported by authentically listening to client-identified concerns and motivation for presenting to the service. This first interaction places an onus on the worker to be alert to the presence of risk and ensures that clients receive the best possible available service for their circumstance.

Identification of presenting needs

Gain an understanding of how and why the client is currently presenting. Identify the strengths (protective factors) that the client is demonstrating. It is critical that you gain a sense of the client’s perception of the concerns and presenting issues and how it impacts them.

Determine client expectations of service intervention. Consider additional supports or information (from Department for Child Protection) that may be required to identify presenting needs.

Risk assessment

Determine any immediate or potential risks to the safety of the child and other family members. Discuss with the client areas of potential risk including child protection, domestic or family violence concerns.

Build an evidence base through discussion with the child and family and your own observations (if possible). Determine the level of risk associated with each factor identified, inclusive of family’s insight into concerns and protective capacity.

In circumstances of family violence, is the perpetrator of violence within the home and willing to engage with services? What is the history of service engagement with the family and what have the outcomes been?

Determine any broader risks to you as a worker or the organisation.

Workers taking accurate and timely case notes (activities undertaken and client responses) provides a record of worker and agency engagement, and additionally lessens clients experiencing ‘service fatigue’ by repeating their story numerous times.

Eligibility assessment

Each program will gather information regarding risks identified by others working with children and their families, including on education sites and in Children’s Centres. Working through concerns assists to identify ‘risks’ or noted concerns, existing or previous service engagement (and outcomes), informal supports and strengths/resilience the child and family have demonstrated, all of which assists in the triage process for line managers.

Child safety assessment

Explore the following factors with the referrer:

• safety issues or child protection issues (abuse/neglect)
• school or day care arrangements (strength of education site connection)
• other agency involvement with the child/family/community
• connection to kinship, nation, community, other extended family
• immediate health issues (nutrition, clothing, medical)
• legal issues, such as court matters, intervention orders (domestic violence) or custody issues (Family Court orders)
• other relevant risk factors, for example mental health, substance use or social isolation.

Determine whether a notification should be made and/or immediate safety response is required and prioritise this action.

Ascertain the parent or kinship carer’s parenting capacity and safety for all family members (consider family violence concerns), particularly with respect to the current crisis and determine support needs.

If possible, has the referrer observed attachment or interaction between parent/carer and child, or directly spoken to the child about the referral and gauged their understanding of what the child’s perspective or wishes might be?

External referral from Safer Family Services

Where possible, ensure a referral is made to a more suitable service, with consent from both child and parent/carer (where possible and appropriate).

Using principles of a connected system, provide adequate information with the referral so the person doesn’t have to re-tell their story. Provide the client with as much information as possible about the referral, for example who they will be seeing, and agree together how they can get there.

Identify other services/agencies involved

Gather information regarding other services involved with the client and their level and purpose for involvement.

Cultural considerations for Aboriginal clients

Where required, an Aboriginal worker should be consulted as soon as possible in the intake/triage process, when children and families identify as Aboriginal or Torres Strait Islander.

Recognise the possibility of service resistance, lack of trust, fear or indifference Aboriginal children and families may present within the context of past experiences of oppression, and systemic racism either witnessed or experienced.

Assertive engagement and compelled clients

Engagement with services can raise a myriad of issues for children and their families. Recognise the imbalance of power, fear, shame or anxiety that may go with parents speaking out or acknowledging safety concerns (for their children, themselves or other family members).

Recognise that risks such as child protection and family violence are often embedded in intergenerational trauma, therefore, children and their families could be cautious of engaging due to previous poor or harmful service responses.

For Aboriginal children and their families, it is likely that any previous service experience did not listen to, consider or respect culture in responses. Additionally, it is highly probable they may have experienced systemic racism.

Compelled clients understand their limited options, namely, they must work with the pre-statutory service or be referred to the statutory authority. Like service resistant clients, compelled clients may have experienced a poor service outcome in either the pre or statutory space, including police and other crisis response services, for example, family or domestic violence services.

Relationship is the key – trust and engagement, encouraging clients to participate in decisions, articulating goals and alternative services available to them, empowering clients and advocating (when required) to remove systemic barriers and considering the client’s possible previous exposure to oppressive practices.

Build on existing strengths and natural support systems and work collaboratively to build sustainable change that supports safety within the home for children and family members.

For Aboriginal children and their families, respect that the kinship system works to keep children safe and connected to culture and nation. Consider allocation of case to an Aboriginal worker as primary practitioner, or consider co- working with an Aboriginal peer to enhance cultural safety for child and family with home visits etc.

Practice point: intake

Each element must be considered within the triage process; the presence or absence of any one element should not exclude further assessment when making the decision to allocate a service response. Line managers will consult each other (if required) on who is best placed to respond – this is influenced by a range of factors including (but not limited to) service capacity and practitioner cultural or service expertise.

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Assessment

Key outcomes

• psychosocial assessment
• risk assessment - child at the centre
• evidence informed assessment
• record information and observations
• assess family strengths, support and patterns
• child protection history and previous interventions
• provide immediate support/ action to promote safety

The assessment process is a dynamic process which involves more than gathering information from multiple sources to inform decision making and case planning. It is an opportunity to work collaboratively, to identify strengths and barriers (formal and informal), to critically review and reflect on competing needs and to prioritise the child’s safety and development (within the family). The paramount driver of risk assessment is the child’s safety, not the safeguarding of the family.

Assessment of needs and strengths across Child Protection Assessment Framework

Explain the assessment process and purpose, beginning with the practitioner role and purpose for involvement. Gaining consent from all family members is considered best practice (including children).

Through respectful engagement and questioning, assess presenting needs within the life domain areas. Ensure a clear understanding from child and family as to the child safety concerns, including their perceived and actual capacity to respond.

Identify the client’s goals, strengths and current support systems, both professional and personal. Gain a good understanding of needs, concerns, values and choices.

Make assessments based on the client’s responses, both verbal and non-verbal. Ensure adequate opportunity to provide input and make their own assessments on different issues; explore what has worked in the past.

Additional services currently involved or with a history of involvement should also be accessed to inform the assessment process. Include any specialist services, for example, medical, with client consent.

When working through the assessment process, be mindful that child protection and family violence are complex issues that often require coordination of multiple service responses, in a decisive and timely way. Feeling overwhelmed as workers (due to complexity and risk) is not uncommon. For children and families, those feeling as amplified by fear of statutory responses, previous poor service outcomes, and feeling inadequate and unsafe.

Complicating factors

What are the complicating factors that impact on the safety of children within the family and/or the family’s capacity to proactively address care and risk concerns? Complicating factors may include (but are not limited to): social or cultural isolation, mental illness, domestic and family violence, underemployment, disability, trauma, homelessness, substance abuse or other forms of addiction.

Concluding an assessment process

Collate all information and observations into a clear evidence informed statement of the client’s situation within each life domain area. Where conclusions are drawn as worker opinions, it is important to be clear about this within case records. Continue to test and explore these opinions through the case management process.

Clearly identify risks within the client’s situation (or behaviours) as well as capacities, opportunities and limitations. In risk assessment, weighing up the child’s immediate safety and development needs, the family’s capacity and desire to change dangerous or neglectful behaviours, and the family and child’s protective capacity all assist in the formulation of the assessment. Consultation with your line manager and supervision throughout this process is fundamental to good clinical governance.

Immediate action and support

As much as possible, work with the client to determine an immediate action plan. Ensure it is clear to the client that immediate action and support is only to address immediate concerns and that, through the development of case plan, longer term action planning can take place.

Cultural responses for Aboriginal clients

When assessing cultural need, understanding what’s most important for the client is critical. Explore the types of supports, networks and family the client may want to connect with and recognise the strength and value of these connections, particularly in supporting culture.

Cultural consultation adds value to assessment and case planning. Accessing Community Elders or Aboriginal workers familiar with client’s nation and community is critical. All attempts to accommodate the Aboriginal client’s preference for an Aboriginal worker or non-Aboriginal worker should be made.

Tools used should reflect the needs of the child, family or kinship group. Recognising the diversity of community and kinship connection, exploring what works for the child, family and kinship group will be important.

Given that the impact of trans-generational trauma, inter-generational trauma and toxic stress is as prevalent today as ever, it is crucial that we adopt respect for and humility towards understanding Aboriginal culture, being mindful of Australia’s colonisation history, dispossession, genocide, the Stolen Generation and historical practices such as segregation and assimilation.

Culturally and linguistically diverse clients, refugees, and new arrivals

Cultural consultation is critical when considering the political, religious, social and economic context and migration experience of children and the family.

It is important to have an awareness of intersectional and gender biases, and an understanding of how these can impact on working within the context of child protection and family violence.

Be cognisant of cultural diversity and how this impacts on family functioning, including (but not limited to) multiple attachment parenting, cultural norms, spirituality and religious practices, and grief and loss.

Also critical is an awareness of the trauma of genocide experienced by refugees fleeing their communities, to the grief and loss, guilt for surviving, and stress of establishing oneself in a new country.

Documenting your work

Tools provide a structured format to collate, guide and synthesise information during assessment processes. Documenting assessments within program timeframes reduces the likelihood of case drift, ensures practitioner accountability, provides evidence to inform line management endorsement (as per clinical governance arrangements) and highlights areas of complexity or requirement for specialised practice.

For Aboriginal children and families, more time may be required to build trust and relationships during the assessment phase. Discuss this with your line manager as timeframes may be extended. Consult with Aboriginal workers or community Elders (if appropriate) to assist with engagement and assessment processes to ensure cultural safety for children and families. Cultural supervision for Aboriginal staff should also be provided.

Practice point: assessment

Synthesise information gathered to consider current context, previous history and patterns, risks identified and protective factors over time. Consider what the urgency is for the child developmentally, culturally and from a secure attachment perspective. What is the balance of risk and protective capacity of family members? Who have you consulted in building your assessment? For example, family violence, mental health or cultural consultants? Who have you reflected with to critically review your practice?

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Case planning

Key outcomes

• the child’s voice is central to the plan (where possible)
• in children and family members’ own words, determine specific goals and how and when these will be achieved
• identify indicators of change – what does success look like?
• Identify risk and respond to safety issues – plan
• celebrate wins and review regularly (reduce case drift)

Case planning is a multifaceted exercise and is not offered in isolation from other supports that the child, family or community may be receiving. Case plans must be centred on meeting the child’s safety needs and may be developed over the course of several meetings with the child and their family. Capturing the child’s voice wherever possible, within appropriate developmental capacity, listening to and documenting their views and wishes for themselves, their family and community is crucial to keeping the child at the centre of the Safer Family Services service system.

Tools to capture case plans may vary according to the needs of the child and family; this is inclusive of cultural needs. As much as possible, incorporating natural (informal) supports within case plans increases sustainability. Work on restorative practices to build and repair informal relationships and kinship systems wherever possible.

Decisive and timely case plans reduce case drift and respond to the sensitivity and urgency that can surround children’s safety. Reducing risk and trauma exposure is a primary consideration for children and families. Regular reviews to identify progress and make adjustments need to be built into the case planning. Line manager endorsement of case plans is required through supervision processes.

Specific goals

Based on the assessment, consider immediate, short- term, long-term and ongoing needs and develop related strategies and specific goals to address these needs. Ensure goals are SMART (Specific, Measurable, Attainable, Realistic and Timely). The safety and best interests of the child are paramount in relation to decisions and actions on the case plan – keep the focus on safety.

Strategies to achieve outcomes

Focus on strengths and natural/informal networks when determining actions, with goals in the child and family’s own words (when possible).

Develop a plan of action for achieving goals with the child and family. Include any other service providers currently or likely to be involved. Ensure all service providers and natural supports maximise the child and family member’s participation with strategies.

Develop goals and strategies that are specific to achieving the desired outcomes. Goals need to primarily focus on mitigating risks to the child and on the child within the context of the family.

Alongside goals, state how they will be achieved, who will be responsible for related tasks and the timeframes for each. Tasks need to be straight forward – a series of steps required to achieve the goal.

Specification of roles and other services

Recognise the plan as a collaborative activity between the case management agency, child, child’s family and community, and other service agencies.

Clarify and document what each individual and agency will contribute to the plan. Clarify the roles and expectations of all involved from both child/family and agency perspective. Set clear and realistic timeframes including clear monitoring and review processes.

Ensure the child and family members are clear about expectations for them achieving their own part of the plan and what they can expect from others. Have all parties sign off on the case plan (if possible) to commit to their agreed responsibility.

Risk assessment and safety

Determine any risk and safety factors for the child and assess the levels of risk. Consider any related legal issues, for example, intervention orders that may require action, including referrals to Family Safety Meetings.

Develop a safety plan with the child and other family members if required. Ensure that the safety plan is distributed to all service agencies, including the school site or children’s centre attended by the child and family.

For Aboriginal children and their families, sharing the safety plan with Elders, kinship networks or community representatives increases the safety of the child and respectfully taps into the safety kinship networks of Aboriginal children.

Cultural considerations for Aboriginal clients

When putting plans together, ensure you have a clear understanding of what the priorities are for the child, family and community. Consult Aboriginal workers wherever possible and appropriate to support case plans. Set goals and timeframes around agreed priorities. If a child or family member appears reluctant to pursue a particular goal, ask questions about their concerns and explore what may be holding them back

When considering timeframes, explain to the child and family why particular time frames have been set and how this reflects a plan towards successful outcomes. When implementing timeframes, be willing to make regular contact leading up to appointments or tasks in order to ensure everyone stays on track. How are community members supporting timeframes and scheduled appointments? Remind the child and family how the task relates to what is an important priority for them. Be prepared to be flexible and make changes to timeframes, particularly if other issues arise that need to be prioritised or addressed above the original task, such as a death in the family or community. Consult Aboriginal staff at crucial points.

Documenting your work

Case plans are the ‘goals’ listed and agreed with children, families and other service providers. It provides a ‘road map’ for children and their families to exit service engagement and ensures transparency and accountability in actions progressing from assessment processes. Make sure documentation works for family – how are things depicted and what does the child and family prefer? Be flexible in your approach. Clinical governance arrangements require direct line manager endorsement of case plans.

Practice point: case planning

When working closely with children and families, at the forefront of engagement is the extraordinary courage and resilience it takes to trust and build a relationship with a new worker or service. Consider the hurt, anger, pain, loss, trauma, war crimes, detention, racism or oppressive practices that the child, family or community may have previously experienced. Children and families need to be given the opportunity to make sense of past experiences (safely), to grieve and to actively build on their resilience, strength, community and cultural connection.

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Implementation of the case plan

Key outcomes

• a child’s right to safety is paramount; focus on safety
• empower children and young people
• exercise wise use of authority – collaborate with the person, not the abuse (Human Services, 2012:13)
• work collaboratively on case plan tasks, consult and obtain consent for referrals and advocacy
• regularly review and share information

Implementing case plans:

• the child’s right to safety and wellbeing is given the greatest weight
• conscious, deliberate and purposeful activity with, and for, the child and their family
• actions that are outcomes focused and work towards case plan goals (set with the child and family)
• engaging and working with all stakeholders and coordinating task orientated responses
• being responsible and accountable to the child, family, community and the plan
• providing accurate and timely case notes on all activities undertaken and the child and family’s responses to them
• adapting new knowledge learnt about the child and family during implementation and regularly reviewing implementation and the case plan accordingly
• for Aboriginal children and family, longer timeframes may be required
• recognise that Aboriginal families may have other competing priorities; being flexible is important while ensuring that the child’s safety is not compromised
• ensuring throughout implementation that consultation with Aboriginal staff is occurring for non- Aboriginal staff working with Aboriginal families

Delivery of case plan tasks

Be action- and solution-orientated, work from a strengths perspective, focusing on the child and family member’s safety, and raising the standard of accountability for those who use violence in the home (majority being fathers).

Implementing case plan actions and tasks is very practical work and requires a proactive and supportive approach to achieving the case goals with children and their families. What’s changed in the implementation phase? Is the child’s safety increasing, has the family’s resilience grown, do family members who misuse power accept responsibility and understand their accountability?

Recognise the importance of the timeframes established and work within these. Be flexible and re-strategise when plans are not working; recognise the importance of review.

Referral and advocacy

Explore options and resources to effectively implement the case plan. Referrals for short- or longer-term involvement of external agencies are likely to be necessary to expand resources and help achieve goals. Involve the whole of the family in referral processes to expand formal supports and sustain changes.

Note that people who have experienced long term oppression through intergenerational trauma may not be able to develop their emotional strength or personal skills to advocate for their own interests, even if this is the most empowering course (Payne, 2014).

Practitioners will at times need to advocate on behalf of their client to ensure access to adequate supports and the involvement of relevant services.

Collaboration and coordination of services

Collaborate and actively build relationships with other service providers to support efficient work, reduce service duplication, remove service barriers, and build a care team around the child and their family working towards the case plan goals with a focus on the child’s safety. Ensure all agencies are aware of each other’s involvement and there is a nominated lead case manager for the child and family driving family meetings.

All agencies remain responsible to the child and family for managing their specific involvement with service tasks (Chappell, 2012).

Communication and information sharing

Maintain open and transparent communication with the child and family members and all partner agencies supporting the case plan. Regular communication helps to maintain a coordinated focus on achieving outcomes and meetings or case conferences with all stakeholders can support this process.

Information shared needs to be accurate, relevant and with consent whenever possible, but not at the jeopardy of the child’s or family’s safety, wellbeing or welfare.

Cultural considerations for Aboriginal clients

Ensure that you engage and inform the child and family about every aspect of implementation as you work on goals and tasks together. Respectful cultural responses are critical when working with Aboriginal families; recognise the safety and strength of the kinship system. Regularly review the safety of the child and family within community. Ensure that consultation with an Aboriginal worker occurs if you are a non-Aboriginal worker working with an Aboriginal family.

Ensure that case plans are intrinsically linked to wellbeing as nominated by the child/family. For example, spirituality, language, cultural connection. Ensure referrals to Aboriginal specific services are prioritised if this is requested by the child and family.

Take the time to listen and demonstrate awareness of the differences across Aboriginal nations by asking about the protocols and practices according to the client’s cultural background and incorporate this advice to provide culturally responsive practice.

Be aware of the intensely personal and ancestral impact of dispossession, past practices and policies on Aboriginal peoples.

Case notes

Case notes are evidence of a program’s sequential recording of client and agency contact while implementing case plans. Case notes provide accountability and transparency in terms of our practice and ensure a record of intervention should a child seek records to piece together their story, or should matters progress through to a statutory response requiring more formal reports for Court.

Practice point: implementation of the case plan

Implementation is the ‘doing’ of all the plans and discussion. Coordinating services, clarifying roles and establishing sound communication processes and accountability will be crucial to successful outcomes for the child and family. Case notes should be a record of the facts including relevant information to the case plan, interventions and ongoing assessment of the child and family’s changing circumstances, however, exclude extraneous or irrelevant information.

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Monitoring

Key outcomes

• review progress and re-strategise
• flexible and responsive to change
• regular case/family conferences as required
• celebrate wins, affirming and validating safety and strength within the child and family
• plan for transitions or exit stage

Monitoring case plan activities with the child, family and relevant kinship connections helps to identify progress, prioritise next steps and ensure efficiency in achieving goals. When working with Aboriginal children, family and kinship networks, recognise that timeframes may need to be extended. This will be determined by the child and family’s previous involvement with services, and their very personal healing journey.

Monitoring case plans is an ongoing and proactive process; it requires constant re-engagement with the child, pivotal family and kinship connections and community contacts, and informing other service providers on progress, gaps and areas that may require change.

Case plan reviews should be conducted every three months with the child and family. Line managers will review a case plan with supervision. Consistent service approaches and accountability to children, families and communities is part of reflective and continuous improvement practices.

A review will determine:

• how is the child travelling with the plan? Are they able to express what’s changed, what is different and how they feel?
• any reassessments needed and which partners need to be involved
• whether identified goals remain current
• whether all strategies are adequately resourced and all partners are contributing towards goal achievement
• additional opportunity to build a relationship with the child and family – can the child’s voice be captured more substantially (if required)?
• if decision making has helped towards identified goals and the impact of goal achievements
• has risk been reduced and from whose perspective? Is there agreement? What is the child saying about this? What are key kinship connections and community contacts saying?

Ensure that monitoring and review includes accurate and timely case notes on all activities undertaken and clients’ responses to them. Our commitment is to ensure a culture of continuous improvement within SFS. The use of internal audits on client files is also beneficial to agency case management standards and quality assurance processes.

Review progress and re-strategise

Engage and support the child and family with acknowledgement of their capacity, growth, insight and motivation. Fundamentally intervention is to mitigate child risk, keep child with their family and build family capacity and improve connection (to support, culture and/or community) to reducing isolation.

Stay curious! About the effectiveness of plans and how emerging information might impact, from your perspective and those of the child, family, extended support system or community. Update and/or refine goals, strategies and objectives to meet the child and family needs, and ensure goals are realistic and achievable. Consider the involvement of additional agencies or supports if necessary.

Identify barriers and respond to change

The monitoring process may identify gaps or barriers to progressing objectives of the case plan. Work with the client and other service providers to identify the challenges/barriers and openly problem solve:

• Is the goal still relevant?
• Has the situation changed?
• What new information may need to be considered?

Systemic critical thinking delivers best responses for addressing barriers experienced by the client. Creativity and persistent, working within the client’s capacity (building resilience and confidence) and agency’s resources.

Celebrate milestones

Celebrate achievements towards goals, successes and acknowledge the efforts of all involved. Ensure the client is at the centre of celebrations and acknowledgement.

Review agency involvement and possible transition or exit strategy

Review if service plan and interventions are still the most suitable/appropriate and if another agency should be the lead in case managing services. Discuss all transitions/ exit strategies with line manager as per governance arrangements.

Cultural considerations for Aboriginal clients

Are goals still relevant and a priority for the client and worker, has child risk reduced? What are some other priorities that will maintain motivation towards this goal? Continue to remain connected to the child and family and demonstrate that you are committed to working with them to make outcomes happen. Understand the long-term oppression and impact of intergenerational trauma and its influence on the child, family and community contact’s confidence and capacity.

Make sure the goals and tasks are developed in a way that works for the community. That the child, family and relevant kinship members can relate to? Ensure cultural consultation has been part of the process or seek co- working with an Aboriginal peer within your team or relevant service that is connected to and understands the child’s nation.

Practice point: monitoring

Providing support and validating good outcomes, while challenging parents or kinship carers on neglectful or other unsafe child rearing practices, is a constant tension for practitioners and the care team.

Clear, transparent and consistent messaging focused on the child’s safety, including exploring additional supports as required by the family, will contribute to maintaining this outcome.

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Evaluation, transition or exit

Key outcomes

• document all rationale for transition, exit or evaluation
• ensure the child, family and other service partners contribute to the transition, evaluation or exit plan
• evaluate progress and outcomes – what’s left to be progressed, why and by whom?
• identify continuous improvement opportunities.

Evaluation is important for:

• measuring achievements against the plan
• reflecting on elements of the engagement process with the child, family and other agencies
• developing evidence informed practice
• reviewing service demands
• recognising service gaps, strengths and opportunities from the child, family and agency perspective.

Transitions and exits are a natural part of the intervention process. Discussions early in the engagement stage help children and families to understand the parameters of the service intervention. For some children, young people and families, this is a motivating factor, especially for families who have experienced oppressive practices which have contributed negatively to their confidence and resilience.

Case transfers within Safer Family Services (SFS) will ideally be led by the child’s developmental, social and emotional needs within the context of their family. For Aboriginal, CALD or refugee children and families, consideration of previous service experiences, trauma history and the relationship established with the current practitioner will be part of the consultation with the line manager supervision. These consultations and final decision making will be clearly case noted by the practitioner and endorsed by the line manager.

Transfers can be prompted by other factors such as workforce shortages. Consultation and agreement is required with program line managers before the client/family and other external partners (Department for Child Protection, school sites or NGOs) are informed of the transfer.

In accordance with Safer Family Services clinical governance, exits from program interventions must be decisions reached in consultation with / under the supervision of your direct line manager.

Recognition of achievements and planning next steps

Include the child and family in the process of evaluation, transition and exit, and be clear about why transition or exit is appropriate currently. Did the child or family initiate transition; if so, why?

Plan the next steps carefully and ensure there is appropriate support in place for a successful transition. Make sure the child, family and other services involved are clear about timeframes and the opportunity for re-engagement if needed in the future.

Reflect with your line manager and learn from the challenges and successes.

Use evaluation to strengthen ongoing practice and partnership

Evaluation might include:

• timing of assessment, or carrying out the assessment
• tools/form/techniques used, and life domains assessed
• any gaps in systems supports or issues
• cultural responses and relevance of service tools and techniques
• the relevance of the information gathered to support case interventions.

Reviewing/ reflecting on practice is part of clinical supervision:

• what were some of the challenges (if any) with engaging the child/family? How were these resolved? What would you do differently?
• is the child safer now within the family? Has the child and family’s wellbeing and resilience improved?
• were cultural connections respected and strengthened during intervention? How was this supported by you and cultural consultants?
• what was new learning for you or others (For example, co-workers)?

Continuous improvement is about reviewing processes, practices and interventions to improve future service response and practices.

Recognition of contributions of all parties

Recognise the efforts, contributions and support of the child, family and each partner.

Transfer of cases internal to SFS

Practitioners are required to consult line managers for approval to transfer. The practitioner is to ensure all assessment and case plans are up to date, including cultural consultations etc. The line manager ensures all documentation is completed prior to transfer, including identification of elevated child protection risks at the time of transfer (timing of transfers must prioritise and support protective factors for the child).

Exit or ending conversation

Children and other participants in the case plan should be aware of the service ending and have an opportunity to reflect and confirm with the practitioner protective capacity and support that has been put in place.

Cultural considerations for Aboriginal clients

If a transition to a new worker or service occurs, ensure the transition happens slowly over several engagements with both workers if this is required by the child and family. The pace of transitions should be determined on a case-by-case basis according to the child and family’s needs. Make sure the new worker has access to information on the history of involvement, levels of engagement and planning for the future. The original worker should provide follow-up after the transition has formally occurred to check on the client’s wellbeing and provide reassurance about the new worker’s involvement.

Practice point: evaluation, transition or exit

Transitions and endings in case management are critical in ensuring that children and families remain connected to services. Exits from services should be completed comprehensively to ensure children and families feel confident to re-connect should they need to. Recognise that endings for children (in particular) can be a time of increased anxiety or concern. For adults with trauma histories, there may be a sense of loss and grief.

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10. Building effective partnership and collaboration

Child protection is a complex issue and, as such, an integrated community and cross-agency case management response offers the best opportunity for addressing child safety concerns and supporting families to care for their children. Safer Family Services is committed to building respectful and enduring partnerships and working in ways that:

• communicate with children, families and others in a way that is entirely respectful; for Aboriginal families, this includes acknowledging diversity in child rearing practices and kinship systems
• reduce service duplication or gaps, avoiding the need for children and adults who care for them, to retell their ‘story’
• respect and invest in enhancing our cultural responsiveness and practice, by building respectful relationships including with culturally specific services and working alongside our Aboriginal practitioners with cultural expertise
• are accountable, transparent, purposeful and timely with a shared understanding, reducing case drift and increasing the likelihood of children remaining safely within their families
• share information that promotes children’s safety and strengthens the family’s capacity to care for their children.

Case conferences (with child and family attending) need to be outcome-driven – generally the purpose of a case conference includes:

• ensuring child and family involvement, including a cultural representative (if appropriate)
• reviewing the child and family situation, agency assessments and progress towards case plan goals
• discussing issues, concerns or gaps in current service delivery (from the child, family and agency perspectives)
• feedback from the child and family members regarding service experience and expectations moving forward
• developing actions (and timeframes) that support the case plan and agree on the roles each agency has in achieving next steps to ensure the child and family support any new direction
• listening to child and family feedback and ensure it is captured and reflected in new case plans.

Case conferences without the child or family present should only be called under special circumstances, specifically if it relates to the safety of the child. Safer Family Services works under the principles of the Information Sharing Guidelines.

11. Conclusion

Safer Family Services (SFS) will embed practice approaches that are child-centred, trauma-informed, culturally responsive, flexible, strengths-based and respectful. This case management framework has been developed as part of a larger suite of resources to guide and prompt case management practice across SFS, including prompting consultations with line managers, specialist peers and Aboriginal workers (as required).

The framework aims to support workers to continually reflect on practice and adapt to the unique requirements of the child within their cultural and family context.

There is a shared purpose and vision that children are able to live safely with their family, connected to culture and community. SFS is committed to this by working with children, families, communities and across the service and support spectrum.

12. Acronyms and glossary

• Acronyms
• Glossary

Acronyms

CMF

Case Management Framework

CARL

Child Abuse Report Line

CALD

Culturally and Linguistically Diverse

DCP

Department for Child Protection

DHS

Department of Human Services

EIRD

Early Intervention Research Directorate, Department of Human Services

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FSM

Family Safety Meeting

HRI

High Risk Infant

ISG

Information Sharing Guidelines

ROA

Refer Other Agency

RSA

Refer State Authority

SFS

Safer Family Services, Department of Human Services

UCC

Unborn Child Concern

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Glossary

Alternate response

Alternative response is a DCP action for a non-investigative response which provides an avenue for a referral to internal DCP services, for example Kanggarendi, Aboriginal Families Project, APY Lands Team and Multicultural Services. It also allows a referral to State Authority for the purpose of a warm referral. DCP can then use a closure code on C3MS, and the service opens an alternative response case to continue recording work with the family.

Assertive engagement

Assertive engagement takes a proactive approach to delivering support. It challenges the idea that a client is always responsible for engaging with services and instead requires that the practitioner persistently and consistently approach the client to build a relationship, to engage them in critical conversations around risk, capacity and functioning, and to continue to offer support.

Child Protection Assessment Framework

The child assessment risk triangle places the infant/child at the centre of the assessment; it considers the infant child’s needs and strengths, the parent/caregiver capacity and strengths, and the family and environment context.

Case plan

A case plan is prepared by a case manager (preferably in conjunction with the client) and is based on a psychosocial assessment of the client, which includes safety, risks and strengths. It clearly articulates how and when needs and goals will be addressed through the process of case management.

Case notes / case recording

Case notes and recordings are written evidence of the history of engagement, assessment, planning, service delivery/coordination and review for the agency/ practitioner with the client. They provide the flow and rationale for key decisions or changes to case plans and demonstrate the outcomes of intervention. Importantly, case records are a source of family history for children and young people, who may later request access information on their family’s story.

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Case worker

A case worker is a worker allocated to provide specific services that support the overall direction of the case plan. They work in close liaison with the client.

Child-centred

Decision-making responds to the unique needs of the child, recognising connection to culture and family, including critical child developmental timelines. Where possible, practitioners actively listen and encourage children to exercise their personal agency and play a significant part in the decision making.

Cultural capability

Services recognise the long history of Aboriginal connection with land and the impact past practices continue to have in community.

Cultural capability is evident at both organisational and service delivery levels, informing decision making and work practices.

Early help and support

To create a first point of contact for anyone seeking advice and assistance if they have concerns about a child, young person or their family’s safety and wellbeing.

Family Safety Framework

Developed to improve integrated service responses to families experiencing domestic violence who are at high risk of serious injury or death.

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Inter-generational trauma

The trauma that a person carries through their life and passes onto their next generation of family.

Relationship-based

Relationship-based social work is based on a supportive and understanding relationship with the client as the key resource.

It does this by addressing the identified problem, and by meaningfully engaging, mobilising and developing both supportive and problem-solving networks, to enhance and foster resilience.

Refer Other Agency

If DCP determines an agency that is not a state authority is better able to respond to a child protection matter and the organisation agrees to accept it, then it is referred to that agency. 24hr responses cannot be referred.

Refer State Authority

Government departments and local councils are considered state authorities, as are any NGOs that receive funding from state or local government to provide services to young people and their families. If DCP determines that it is more appropriate for a state authority to respond to a child protection report, the report may be referred to that authority for a response. This must be done in agreement with the authority. 24hr response intakes cannot be referred.

Restorative practice

Restorative practice is a strength-based practice that seeks to repair relationships that have been damaged.

It empowers families to influence and participate in decision making that will produce positive outcomes for their children.

Restorative practice engages families and enables change by working with families rather than services doing to them, or for them.

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Priority groups for Safer Family Services

Priority groups include:

• young parents (mothers under 20 and fathers under 25 at the birth of their first child)
• vulnerable adolescents at risk of having children who will go on to enter the child protection system
• Aboriginal families with multiple needs
• families of infants at risk in the first 1,000 days.

Trauma-responsive practice

A strengths-based framework grounded in recognising, understanding and responding to the impact of trauma, emphasising physical, psychological, and emotional safety, and creating opportunities for clients to rebuild a sense of control and empowerment.

Trans-generational trauma

Occurs when the grief and loss from one generation is passed to future generations.

Toxic stress

Toxic stress in children, stemming from abuse, neglect, exposure to violence, and/or the stresses of poverty, is a risk to healthy development and its underlying brain function and may increase the risk of a variety of chronic diseases later in life (SNAICC, 2019).

Warm referral

‘Warm referral’ has varying meanings according to the service context. Within Department for Child Protection (DCP), it describes a joint home visit from DCP and Safer Family Services practitioners.

For Safer Family Services programs, it is supporting client and agency to connect by contacting an agency prior to the client. This ensures the receiving agency has all the information required in order to accept the referral and provide the client with the services they require.

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13. References

1. Chappell, C (2012) Case Coordination Handbook: a field guide to the care planning and management of people who have complex needs and occupy public places in Townsville, Accessed 2 Nov 2012
2. (COAG) Council of Australian Governments (2009) Protecting Children is Everyone’s Business National Framework for Protecting Australia’s Children 2009–2020
3. Child Protection Assessment triangle website accessed 5 Dec 2019
4. Creative Spirits (2019) “How old is Aboriginal Culture? - https://www.creativespirits.info/aboriginalculture/history/how-old-is-aboriginal-culture” website accessed Nov 2019
5. Early Intervention Research Directorate (2019) An Intensive Support System for South Australia’s children and families, March
6. Gronda, H (2009) What makes case management work for people experiencing homelessness?: evidence of practice, AHURI Final Report No. 127. Melbourne. Australian Housing and Urban Research Institute.
7. Human Services (2012) Best interests case practice model, Summary Guide State Government Victoria
8. Information Sharing Guidelines - https://www.dpc.sa.gov.au/responsibilities/information-sharing-guidelines (website accessed 5 Dec 2019)
9. Lawrie, A (2019) Commissioner April Lawrie, National Child Protection Week, Q&A Forum, Adelaide 6 September
10. Payne, Malcolm (2014) Modern Social Work Theory 4th Edition, Palgrave
    Macmillian UK
11. Secretariat of National and Aboriginal Islander Child Care (SNAICC) website Child Rearing Practices - https://www.supportingcarers.snaicc.org.au/caring-for-kids/child-rearing-practices, website Accessed 25 Nov 2019