Case Management Guidebook

Comprehensive guidance and support to professionals working in homeless and drug services

How to use the Guidebook


This guidebook has been developed as a companion to the Holistic Needs Assessment (HNA) and Support Plan (HNA), which is the common assessment tool developed by the Homeless Agency Partnership. The guidebook will be useful for key workers, case managers and line managers involved in assessment and support planning. For ease of use, the term case manager is used throughout to aid the reader.

Holistic Needs Assessment

The HNA is a voluntary single shared assessment system, which aims to provide opportunities for any individual who experiences homelessness to engage in a process of planning and action, which is person centred. It provides a valuable space within which the individual can determine their own pathway out of homelessness, taking into account the full range of their circumstances and needs. The benefits of implementing the HNA across homeless services include:

  • Reduction in the number of times that a service user is assessed.
  • Ensures continuity of support for the service user.
  • Reduction in the number of assessments that staff undertake.
  • Promotes consistency of assessment practice between organisations.
  • Improves information sharing between services.

The assessment and support plan have a generic, holistic approach rather than a specialist, diagnostic approach. For this reason, it is important that key workers, case managers and line managers can access relevant information on a very broad range of issues, in order to address all needs, which have been identified in the assessment and which require follow-up in the support plan. All twelve domains of the assessment have a corresponding chapter in the guidebook, which aim to inform the key worker, case manager and line manager of the most appropriate course of action to take in the event that any particular need has been identified.

The HNA focuses on 12 key support areas:

  1. Accommodation/Homelessness
  2. Family and Current Relationships
  3. Early Life Experience and Childhood
  4. Education
  5. Work and Job Training
  6. Legal Issues/Offending Behaviour
  7. Income and Finance
  8. General Physical Health
  9. Mental Health
  10. Alcohol Use
  11. Drug Use
  12. Independent Living Skills

The HNA was used by all homeless and addiction services involved in the Case Management Interagency Protocols Pilot and is one of the foundation tools in ensuring a common understanding of the case management way of working.

This guidebook is divided into three sections including:

A Key Support Interventions

B Interagency Protocols

C Listings

A Key Support Interventions

The Key Support Interventions section includes 13 chapters reflecting the domains of the Holistic Needs Assessment, with the addition of a chapter on Equality issues, which is a cross-cutting issue. Where a topic refers to a HNA question, this is indicated in the topic title (e.g. Q1.3-1.9).

Every chapter has a similar structure, which includes the following aspects:

  • An outline of key goals to be achieved when working with the service user.
  • An overview of the context for the services and supports available on that issue.
  • A list of key support interventions: this forms the main detail of each chapter. Each intervention has a corresponding description as to how the key worker or case manager can respond to the issue affecting the service user. Where there is only one service available to assist the service user; the service will be named. Where there are a number of possible referral options; the reader will be directed to a relevant section in the listings.
  • The chapter ends with a brief list of relevant policy documents.

B Interagency Protocols

The Case Management Interagency Protocols1 have been developed to guide the working processes of frontline professionals in homeless and drugs services. The purpose of the protocols are to:

  • Clarify the way in which multiple agencies can work together to assist the client in achieving their personal goals.
  • Ensure that service users do not fall through ‘gaps’ in services provision.
  • Reduce duplication of services.
  • Improve outcomes for individuals with high support needs.

C Listings

The listings aim to provide a comprehensive list of services available. The listings are divided into 11 sections reflecting the 13 chapters in the guidebook and the domains of the Holistic Needs Assessment (Education and Work and Job Training have been combined and Independent Living Skills does not have a section in the listings). The information varies for each service group to ensure that each key worker or case manager has the relevant information that they need. There is an alphabetical index of all services at the end of the listings.

1 In relation to homeless services the protocols were developed and trialled in 28 different homeless services across the spectrum of the continuum of care, from within the Dublin region. The Board of the Homeless Agency Partnership adopted these protocols for use in homeless services in November 2009. In relation to drugs service, the protocols were established and trialled in 10 different drug projects within the North Inner City Local Drugs Task Force and South Inner City Local Drugs Task Force areas. These protocols have not been agreed by all drugs services within Dublin. The evaluation of the pilot of these protocols will be fed into the National Drugs Rehabilitation Implementation Committee to contribute to future policymaking concerning case management within the sector.