Case-management functions
Assess barriers
Identify the concrete factors affecting access, safety, participation, functioning, and treatment goals.
Plan the next step
Define the task, responsible role, due date, evidence of completion, and what happens if the first plan fails.
Coordinate systems
With consent, connect providers, family, schools, courts, housing, benefits, employers, medical care, peers, and community resources.
Refer and advocate
Help the person understand options, preserve choice, provide necessary information through approved channels, and address barriers.
Monitor and follow up
Track whether the receiving service accepted the referral, whether the appointment happened, and whether the intervention helped.
Close or revise
Document completion, an alternative plan, escalation, or a clinically appropriate transition.
The completed-handoff standard
- 01Receiving option identified
- 02Contact made
- 03Acceptance established
- 04Appointment or next step scheduled
- 05Person or caregiver informed
- 06Access barriers addressed
- 07Attendance/outcome tracked when appropriate
- 08Closure or revised plan documented
Common capacity domains
Reach One may help navigate these domains; it does not guarantee the availability or outcome of an external resource.
Housing and utilities
Safe housing, shelter, tenancy, utilities, furnishings, recovery housing, or a completed redirect.
Transportation and access
Transit, rides, technology, mobility, scheduling, identification, and route planning.
Benefits and financial stability
Applications, renewals, documentation, budgeting connection, food resources, and public systems.
Medical and psychiatric care
Primary care, medication, pharmacy, psychiatry, specialty care, discharge follow-up, and information exchange with consent.
Work and education
Readiness, applications, accommodations, schedules, training, placement, retention, and barrier reduction.
Legal and family systems
Court, probation, child welfare, custody, family supports, identification, and advocacy within scope.
Source and publication control
Designed from Reach One’s controlled planning record
This page is generated from the Reach One website/strategic planning package, SPW readiness baseline, executive decision register, program-design materials, and website build charter. Production publication still requires current evidence, named approval, workflow testing, and a rollback path for any claim that can change.