Restorative Care Pathway Case Management Activity
Goal Planning
Service Planning and Management
Monitoring, Review and Evaluation
• Identify the client’s needs, goals and preferences, in alignment with the support plan
• Establish and review the service agreement
• Develop and review the goal plan and budget
• Initiate referral to required services and support, including Allied Health and Nursing
• Coordinate clinical supports and communicate with the client, their registered supporter and the Restorative Care Team to ensure effective, personcentred, and goal-focused service delivery.
• Manage the Restorative Care budget
• Support access to AT-HM Scheme, where required
• Conduct care discussions with the client, their registered supporter and the Restorative Care Team, where required
• Conduct case conferences with the Restorative Care Team
• Submit a support plan review, where required
• Evaluate the client’s goals, service quality, and outcomes
• Complete and submit exit plans
Support and education
• Support delivery of services with wellness and reablement resources
• Provide advice, information and resources on age-related health matters
Total Care Management Hours: 9–13 hrs per episode*
*The volume of care management hours will vary according to client needs and complexity.