Service Coordination & Case Management

Instructions to students

Please answer every notebook activity questions in this document and submit your file electronically via Turnitin on the LMS page. Each notebook activity has a 500-word limit (there is no 10% grace to extend beyond this), making the maximum word count for this assessment 2000 words. If you intend to use literature to support your answers, use APA6 referencing. If you are new to this referencing system, or would like a refresher, La Trobe University library has a great tool to help you cite academic literature: click this link to find out more information about APA6 style. Your references and citations are not included in the word count.


If you have any questions about this assessment, we invite you to post these on the LMS message board and a member of staff will respond to them promptly. ?




Notebook Activity 1

This case portrays a woman who has chronic health problems, which are deteriorating and limiting her capacity to remain at home without a significant introduction of community based supports. The case also demonstrates a significant use of acute health services including a complex array of health professionals and interventions. Read the below case study and answer the questions.


Background Information

Naomi is a 74-year-old woman who lives alone and has no children. She suffers with multiple co-morbidities including: congestive heart failure (CHF), pulmonary hypertension, chronic renal failure, failed right femoral bypass, chronic leg ulcers, psoriasis, diabetes, retinopathy, hypothyroidism and epilepsy. The main symptoms related to her health issues include pain and difficulty sleeping due to arterial insufficiency in her leg, constipation and exacerbations of CHF; however, Naomi is reluctant to accept further vascular surgery and is also reluctant to accept home support services. Naomi prefers to use the local acute public hospital for medical care and only attends her local GP for repeat prescriptions.


Over a six-month period, Naomi presented to the Emergency Department five times and was admitted to the ward on four occasions, transferred to Hospital in the Home (HITH) on two occasions (one being a direct admission) and transferred to a step-down facility on another occasion.


Additionally, Naomi attended four different outpatient clinics on numerous occasions and had input from allied health including social work, podiatry, physiotherapy, occupational therapy, a diabetic educator and community nursing. Follow up outpatient’s appointments were arranged after each admission and clinical information forwarded to the GP.




Answer the following questions based on Naomi’s information


Question 1

What is the HITH program?


Hospital in the Home (HITH) provides a home base care that a patient would receive being in a hospital environment in the comfort of his or her own home.


This allow patients to have the continuity of care in their own home for better recovery or on going treatment that can be provided at home by their hospital doctors and nurses. It is an alternative way that patients are provided with the option for the HITH care with no further cost to the patient (Hospital in the Home”, 2018).


HITH involves 24 hours support for carers and/or family members to have access to services such as medical education and advice. Furthermore discharge arrangements are done through implementing consultations with Family doctors and the appropriate community base services for inpatient home care needs.


Hospital in the Home. (2018). Retrieved 22 April 2018, from



Question 2

What would be the key care objectives for Naomi?






Question 3

Outline a series of activities (i.e., behaviour change) that a service coordinator or case manager could take if appointed to coordinate care for Naomi.








Notebook Activity 2

Read the following case scenario and answer the questions below


John is a married 49-year-old building worker. One year ago, John had a minor car accident on his way to work, and since then he has been complaining of intermittent headache and backache. He has not been employed since the accident and is currently on unemployment benefits.


The TAC paid for the initial medical costs and is still supporting John’s regular physiotherapy sessions. The current medical certificate suggested spondylitic changes to his spinal column, and this could make it difficult for John to do heavy lifting but would not make him unable to work.


John’s previous employer has been downsizing the firm’s workforce and reports that there is no position available for John. John’s work skills are limited to those associated with his previous work as a builder’s laborer. John says that he has been advised by a community support worker that he was ‘probably too old to find the same sort of work’ with a new employer.


John did not complete secondary education and he is very reluctant to take on any new training as he feels he will be too slow and made to look ‘dumb’. John has a brother-in-law who is on the disability support pension (DSP) and is urging John to try and get on this benefit rather than unemployment benefits.


Most of John’s friends were workmates and he is now he is now quite socially isolated; for example, he no longer goes to the football with his mates because he feels embarrassed about his unemployment. Relationships are tense with family members complaining that John is very irritable and prone to anger outbursts.


You have spoken to John recently and find he is very down. He says he is depressed; he feels that he has been put on ‘the scrap heap’. He says his back is getting worse and that his wife is suffering because of his condition.




Answer the following questions based on John’s history and case


Question 4

Identify and discuss John’s health condition in light of the ICF framework.











Notebook Activity 3

Standard comprehensive assessment instruments


A variety of different tools have been developed for comprehensive assessment of older people. These include:


  • EASY-Care,
  • InterRAI suite of tools,
  • FACE (Functional Assessment of the Care Environment for Older People),
  • Carenap (Care Needs Assessment Package),
  • CANE (Camberwell Assessment of Need for the Elderly).



Question 6

Your task is to describe and compare two of the tools listed above, or you can select instruments not listed. Note: information about each tool can be accessed via commercial web sites but you are encouraged to search databases for psychometric studies about assessment instruments.


When attempting this question, compare the features (or lack of) and purpose of each tool and use literature to help support your answer.






Notebook Activity 4


What if one of the assessment tools you discussed in notebook activity 3 is used to assess an older person from a non-English speaking background?



Question 7

Discuss the cultural implications of using this assessment tool with a client from a non-

English speaking background.





Question 8

Discuss limitations of the chosen assessment tool in that non-English speaking context.

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