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  • 7/24/2019 NCSS - CareandDischargeGuide


    Care and Discharge


    A Guide for Service Providers

    Serial No: 032/SDD19/DEC06

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    Acknowledgements 2

    Feedback 3

    Foreword 4


    1 Introduction 7

    2 Components Of A Care And Discharge Plan 10

    3 Guiding Principles 12

    4 Workflow 14

    5 The Process 15

    6 Checklists 18

    Annexes 19

    References 28

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    The National Council of Social Service would like to acknowledge the followingorganisations for their invaluable inputs to the development of this guide:

    Disability Information and Referral Centre

    Hua Mei Care Management Service

    Ministry of Community Development, Youth and Sports

    Methodist Welfare Services

    Society for the Physically Disabled

    Singapore Anti Narcotics Association

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    This document is published in November 2006 and will be reviewed periodically.

    NCSS welcomes your feedback.

    Please write in to:

    Strategy and Specialisation Department

    Service Development Division

    National Council of Social Service

    170 Ghim Moh Road #01-02 Singapore 279621

    A copy of this guide can be downloaded fromNCSS website.


    [Visit NCSS website; go to VWO Corner; Resources; and scroll down to Service


    National Council of Social Service. All rights reserved. No part of this manual

    may be reproduced or transmitted in any form or by any means, electronic or

    mechanical, including photocopying, recording or any information storage and

    retrieval system, without written permission from the National Council of Social


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    This guide is part of a series of guides1

    on good practices for service delivery.

    These guides compliment the Best Practice Guidelines2

    checklist for VoluntaryWelfare Organisations (VWOs) and Non-Profit Organisations (NPOs) to conduct self-assessment of their organisational practices and processes.

    2 It is hoped that the guide will help improve processes to achieve the

    programmes outcomes for its clients. This guide is designed to provide a reference

    on care and discharge planning processes for community-based social service agencies

    in Singapore. It also serves to highlight the minimum standards which agencies shouldstrive to achieve. The minimum standard for Care and Discharge Planning as outlined

    in the Service Standards Requirements are:

    Care Planning

    (1) The programme has written procedures on individual care planning.

    (2) Care plans are tailored individually to meet the unique needs and

    preferences of the service user and/or his/her family.

    (3) Re-assessment of care plans are conducted at regular intervals (at least 6monthly) or as agreed between NCSS and the VWO.

    Discharge Planning

    (1) The programme has written procedures on discharge planning.

    (2) Discharge plans are discussed at the onset of service provision with theservice user, his/her family and concerned individuals involved in the

    care of the service user.

    1 Other Guides already published are: Guidelines for Practising Therapists in VWOs (2003); Standards of

    Practice For Physiotherapists, Occupational Therapists & Speech-Language Therapists (2003); SpecialisedCaregiver Services - A Guide for Service Providers (2004); Case Management Service - A General Guide forService Providers (2004); and Intake and Assessment - A Guide for Service Providers (2006).2

    The Best Practice Guidelines, currently a self-assessment checklist of 54 areas, will be streamlined to theService Standards Requirements (SSR) from April 2007. The SSR is a set of 16 mandatory requirements whichhave a direct impact on client outcomes.
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    3 This guide consists of:

    the guiding principles for the development and delivery of quality care

    and discharge planning;

    the processes for the development of the care and discharge plans; and,

    checklists and templates for care and discharge planning.

    4 Organisations are expected to develop and customise their care and discharge

    policies and procedures using pointers from this guide. The framework recognises

    that the nature and clientele of each programme varies, and accordingly, the

    availability of human and financial resources. These factors will influence the type

    and extent of care and discharge plans adopted for each client.

    Target audience

    5 This guide is designed primarily for organisations that provide community-

    based social services for persons with disability, seniors, children, youth and families

    in the community, in Singapore. The programmes are typically client-centred, as

    opposed to group-based programmes. However, agencies which conduct group

    programmes and mass outreach may also adopt a care plan for their vulnerable clients.

    6 This guide is intended for the following programmes:

    Aftercare Case Management Service

    Befriending Services

    Caregiver Support Service

    Client Re-integration and Family Services

    Community Case Management Service

    Counselling Centres

    Day Care Centres for Seniors (Social, Dementia and Rehabilitation)

    Early Intervention Programme for Infants and Children Family Service Centres

    Home Help Service

    Home Therapy

    HostelsDisability and Mental Health

    Integration Support Programmes

    Production Workshop

    Mentoring Services

    School Social Work

    Sheltered Workshops (employment services) Training and Transition Programmes

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    Other organisations involved in the care of clients.

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    Chapter 1


    A What is a care and discharge plan?

    1 A care plan puts down on paper who is providing which service to meet theneeds of the client. Goals and outcomes are set, and a plan of action is decided within

    specified timeframes, in consultation with the client, and their caregivers, if any.

    2 A discharge plan puts down on paper the end-goals of the care plan, which

    ultimately aims to empower the client to make decisions and be resilient, to maximise

    his potential to live independently, or to enable him to tap on support and resources

    within his family or the community. Discharge planning is a process used to decide

    what a client needs to maintain his present level of well-being or to move on to the

    next level of care.

    B How does it benefi t clients?

    3 Clients benefit from care and discharge planning because it:

    Sets goals with and for the client and provider according to clients


    Encourages a team approach by both formal and informal caregivers;

    Manages long-term care by setting milestones; and

    Ensures continuity of care.

    C Why do we need the plan?

    4 A documented care and discharge plan would help all parties involved in the

    care of the client, and the client himself, to have a clear understanding and expectation

    of the plan of action, including his expected discharge. Without the plan, ambiguities

    may arise as to the role and expectations of service providers, as well as the

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    motivation of the client to engage actively in the programme. The care plan spells outmilestones of achievement as well as decides on the agreed outcomes of intervention.

    D Why is it important to conduct care and discharge planning together?

    5 In the business of caring and providing social service, it is important for serviceproviders not to under or over-provide for the client. A discharge plan, when planned

    at the start of engaging the client, helps providers bear in mind the ultimate aim of

    providing supportive services to the client. i.e., to empower the client to maximise hispotential and autonomy given his abilities and unique conditions.

    E Who needs care and discharge planning?

    6 Clients who have multiple or complex needs arising from the interaction of

    physical, medical, social and emotional needs will benefit from a clearly documented

    care plan. They need skilled assessment and comprehensive management of services.

    They typically require well-coordinated care and supportive services, and there is a

    need for ongoing monitoring and review of the clients changing care needs.

    Examples of clients who would benefit from a care and discharge plan would be frail

    older persons who live alone or with minimal family support, children and adults with

    disabilities and ex-offenders.

    F When is care and discharge plann ing conducted?

    7 Care and discharge planning should be conducted within an optimal timeframe

    for clients. Organisations should develop their own timeline for care and discharge

    plans, in tandem with its philosophy of care and intended client outcomes.

    8 Usually, care and discharge planning would be conducted after intake

    assessment. For more information on intake assessment, refer to NCSS Guide on

    Intake and Assessment (2006).

    9 Agencies can use the electronic Case Management System (eCMS) todocument care plans. eCMS allows for information sharing across service providers,

    which would facilitate referral, monitoring of client progress and follow-up.

    G Who is involved in care and discharge plann ing?

    10 The case manager would take the lead to implement, co-ordinate and monitor

    the progress of care and clients readiness for discharge. The client and caregiver

    (parent, guardian or family) and/or significant others should also be actively engaged

    and consulted in the care and discharge planning. If necessary, a multi-disciplinary

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    team involving various professionals would assess the client and recommend

    strategies and a plan of action to achieve the agreed outcomes.

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    Chapter 2


    11 Care planning should include consideration of the following:

    (1) Strengths, Needs, Abilities and Preferences (SNAP) of the client;

    (2) An interpretive summary;

    (3) Specific, Measurable, Achievable, Realistic and Time-bound (SMART)

    milestones and outcomes;

    (4) Intervention plans and community partners to achieve goals;

    (5) Transition and discharge plans, including criteria for discharge or

    transfer; and,

    (6) Roles of client, family/caregiver, staff, volunteers and others in the

    support network (e.g. neighbours).

    12 Discharge planning should include consideration of the following:

    (1) The clients current condition (physical, mental and social condition),and any changes that may have occurred as a result of intervention/service rendered;

    (2) Anticipated symptoms, problems or changes that may occur after

    discharge, including factors of stability within clients circle of support,

    or factors of uncertainty which may tilt the clients life equilibrium;

    (3) Recommendations for follow-up care or services;

    (4) The potential impact of caregiving on the caregiver, and caregiver

    needs, training and resources;

    (5) Community and sources of social support for client and caregivers,

    including agencies that provide services such as transportation,

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    equipment maintenance, respite care, home care, job referral andvolunteer services;

    (6) Information resources such as pamphlets, videos, books and websites;


    (7) Contact details (including name of contact person, telephone and email)

    of the discharging organisation for information or help.

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    Chapter 3


    13 The following are some guiding principles to consider in care and discharge


    A Client-centred

    14 A caseworker should proactively engage and empower the client (and

    caregiver, if any), carefully consider his preferences, and be sensitive to his unique life

    experience and circumstances. The care plan should be appropriate to the clients

    culture and age, and based on his strengths, needs, abilities and preferences.

    Caseworkers, in the helping effort, apart from focussing on the clients needs, should

    give due understanding of the clients strengths, abilities and preferences, which can

    be tapped on to ensure success of intervention. The caseworker should also tap on the

    clients natural support network, such as family, neighbours and nearest provider to

    his home.

    B Flexibility

    15 The care plan should be flexible to address changes in the clients

    circumstances and environment, reviewed regularly and modified accordingly. This

    will ensure that the care plan remains relevant. The client should be asked for his

    concensus and kept informed of any changes made to the care plans. If the agency is

    unable to provide a particular service to address the clients needs, this should also be

    recorded. The agency should then refer the client to a provider who can meet the

    needs, and follow-up accordingly.

    C Communication to client

    16 A caseworker should explain the purpose, benefits and process of care planning

    to the client and caregivers, and address their concerns. The care plan should be

    conveyed to the client in a manner and at a level and pace that is appropriate to their:

    personal background (profession, religious and ethnic sensitivities);

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    language and preferred ways of communicating;

    their current intellectual, mental and emotional states; and,

    the presence of any physical impairment (e.g. hearing and visual).

    D Enhance quali ty of li fe

    17 When assessing a client, the caseworker needs to be open and honest about

    what action plans are critical and necessary, and what is open to compromise and

    negotiation. There is a need to prioritise the action plan, as not all changes can be

    effected immediately. Caseworkers must be aware that their individual values,

    cultural background and principles may influence their assessments. The driving

    principle should be that the changes proposed should enhance the quality of life of theclient and his family, or caregivers.

    E Respect client conf identiali ty

    18 The client or clients parent/guardian should be informed that personal

    information may or will be shared with other various service providers, if necessary,

    to ensure continuity of care. The caseworker should hence obtain the clients or his

    parents/guardianconsent through signing of a consent form, and respect his wishes if

    there is any personal information that he does not wish to be disclosed to anyparticular person or agency. Due discretion must be applied. The above may not

    apply to emergency situations, or where the safety of the client may be compromised.

    The client should also be informed that his personal information may be required for

    typically aggregated statistical studies of trends and patterns; service reviews or

    service planning. Refer to Annex 1 for guiding principles of information sharing.

    F Acknowledged by client and provider

    19 Both client and provider should sign the care plan after it has been presented tohim. In the event that the client is unable to do so, the caregiver can be asked to

    acknowledge the plan.

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    Chapter 4


    Intake assessment Chart 1: Care and Discharge

    Planning Process


    Needs assessment, if necessary by a multi-disciplinaryteam

    Interpretive summary

    Establish care and discharge plan inconsultation with client and

    caregiver/significant others

    Implement care plan

    Monitor outcomes, review care plans according to clients

    changing needs and progress

    Prepare for dischargedetailed discharge plan, including

    follow-up plans



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    Chapter 5


    A I ntake assessment

    20 Assessment is a way of learning important information about a client so that hiscritical and real needs are ascertained and appropriate service determined.Assessment should include the clientsphysical and mental health profile; family andsocial history; formal and informal support systems, activities of daily living, mentaland emotional status, community and financial resources, interests, hobbies and past

    work history3. The key assessor in charge of putting together the care plan is required

    to get a wholepictureof the clientscircumstance to best and most effectively meet

    the needs of the client. If possible, the caregiver should attend the initial assessment

    with the client to give a more holistic picture of the client.

    21 It is important to note that clients with special needs and concerns may requireadditional assessments such as speech, audiology or psychological evaluation. Ahome visit can be conducted, if necessary, during this stage or when feasible toidentify home safety issues, home medication use, use of or need for adaptive devices

    and the optimal functioning of the client and caregiver at home4.

    B Admission

    22 The client is admitted to the programme if he meets the agencys eligibilitycriteria. The eligibility criteria should be transparent to users and well-documented.

    C Needs assessment

    23 It would be ideal if all who are involved in the care and discharge of the client

    meet to discuss on the care and discharge plans. However, this may not be possible

    in some cases. Agencies can be flexible in terms of where and how the planning is

    conducted. Care must be taken to ensure that all parties, including the client, agree

    with the plan, to understand and agree on each partys role and responsibilities. As

    3 Reference: Guidebook on Dementia Day Care Centres, Ministry of Health, Singapore, 20024


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    the plan may involve professionals from one or multiple agencies, due care must betaken to ensure minimal misunderstanding or miscommunication.

    D I nterpretive summary

    24 Once the clientsstrengths, needs, abilities and preferences are identified in the

    intake or needs assessment, the case manager should develop an interpretive

    summary. This summary indicates the caseworkers diagnosis or interpretation of the

    clients needs based on information obtained during assessment. The summary links

    co-occurring issues and makes a professional judgment on the connections between all

    issues raised in order to prioritise goals and intervention.

    E Establish care and discharge plan

    25 The care plan lists and prioritises set specific, measurable, achievable and

    realistic outcome/s within an optimal timeframe. Important milestones should also be

    set and clearly stated to measure progress. The goals/desired outcomes should be

    described in terms of observable client response. This would help motivate the client

    and the caseworker as there is a sense of achievement, particularly when difficult

    lifestyle changes need to be made.

    F Implement care plans

    26 Whilst implementing the intervention strategies to achieve the stated outcomes,it is important to involve and empower the client, and ensure self-determination as far

    as possible. Monitoring of the progress of the client should be conducted

    systematically, at scheduled review dates or when the clients circumstances had


    G Discharge

    27 Discharge planning should start at the time or even prior to admission. The

    purpose of discharge planning is to identify the clients plans after exiting the

    programme, and the support which the client and caregiver would require after


    28 Case workers coordinate discharge for the client by collaborating with the

    client, and if necessary, family and community care resources. Ideally, a thorough

    care system should be adopted where the caseworker who assessed the client and who

    developed the care plan should oversee the discharge. Familiarity with the client willensure continuity of care, optimal use of resources and the clients existing support

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    network, as well as responsiveness to the clientspreferences and anticipated changein needs. As with developing the care plan, the discharge plan should also be well-


    H Follow-up

    29 The date and proceeds of the post-discharge review should be indicated in the

    case notes. Questions to ask the client in order to assess the adequacy and

    effectiveness of the discharge process include:

    How are you coping?

    Do you have any questions?

    Have you received the services arranged prior to the discharge (for e.g.

    escort and transport service for medical appointments, home

    chores/meal services?

    Is your caregiver able to provide adequate support?

    What has changed?

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    Chapter 6


    30 The adoption of standard checklists, templates, forms or letters will ensure

    clarity and objectivity in assessments, thoroughness in the process and common

    understanding and interpretation of needs and treatment. The checklist provides

    guiding questions to ensure standards of care for clients when providers develop care

    and discharge plans. Below is the suggested list of standard documents which can be


    (1) Care plan checklist (sample at Annex 2).

    (2) Discharge plan checklist (sample at Annex 2).

    (3) Template for care and discharge planning (sample at Annex 3).

    (4) Letter of consent on disclosure of personal data for emergency and

    statistical compilation (according to each agencys procedure andpractice).

    (5) Letter of referral to next agency (according to each agencys procedure

    and practice).

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    Annex 1

    Privacy Concerns - Principles Of Information Sharing

    Before releasing information, agencies need to consider:

    1. Is there a legitimate purpose for you or your agency to share the information?

    2. Does the information enable a person to be identified?

    3. Is the information confidential?

    4. If so, do you have consent to share? Has the client/ clientsparent or guardiansign a consent form?

    5. Is there a statutory duty or court order to share the information?

    6. If consent is refused or there are good reasons not to seek consent, is there

    sufficient public interest to share the information?

    7. If the decision is to share, are you sharing the right information in the right


    8. Have you properly recorded your decision?

    Source: Every Child Matters, Change for Children, Making it Happen Working

    Together For Children, Young People And Families , UK.
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    Annex 2

    Table 1: Care Plan Checklist

    Care Plan Checklist Yes No

    1. The clients strengths, needs,abilities and preferences (SNAP) aredocumented and considered.

    2. The client and caregivers are consulted, and their preferences are

    accommodated (where possible).

    3. The plan is appropriate to the clients culture, age, physical status

    and mental state.

    4. There is an interpretive summary.

    5. The goals are SMART specific, measurable, actionable, realistic

    and time-bound.

    6. The roles of all persons involved to achieve the goals are stated.

    7. There is a date set for review, and the care plan modified


    8. The care plan is dated and signed.

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    Table 2: Discharge Plan Checklist

    Discharge Plan Checklist Yes No

    1. The clients strengths, needs, abilities and preferences (SNAP) at

    the point prior to discharge are documented.

    2. The gains from participating in the programme, or goals achieved

    are documented.

    3. The likely post-discharge needs and issues are identified andconveyed to client and caregiver, if any.

    4. Referral to other agencies for post-discharge needs are made, where


    5. Caregivers are briefed on client needs, and informed with other

    resources available, including caregiver support groups, respite

    services and other community resources.

    6. Contact details of a staff from the discharging organisation has beengiven to client and caregiver.

    7. A designated staff had been assigned to follow-up with the client

    and caregiver, within a specified time-frame.

    8. Information resources, such as pamphlets of community-based

    services, health-related information (disease prevention, nutrition or

    diet, coping skills for caregivers, etc.) had been given to client and


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    Annex 3

    TEMPLATE OF A CARE AND DISCHARGE PLANAgencies can modify the care plan to suit unique programme needs

    Section 1: Referral Information

    Referral Source: (E.g. CDC, Hospital, FSC, etc)

    External Referral No.:

    Date of Referral: Date of Receipt:

    Name of referrer/Designation:

    Contact Numbers

    (Office, Mobile, Email:)

    Current Location of


    Section 2: ClientsParticulars

    Case Reference



    Contact nos.

    (Home, Mobile, Email)


    Religion Gender




    Date of Birth Age

    Section 3: Caregivers Information

    Has Primary Caregiver Yes


    Relationship to client :

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    Name of


    Next of Kin



    Contact Numbers

    (Home, Office, Mobile,


    Nationality Marital


    Section 4: Intake Assessment

    Presenting Problem

    Underlying Problem E.g. Abuse/Neglect; Addiction; Care Arrangement/ Shelter;Caregiving Issues; Elderly Issues; Employment Issues; Family

    Issues; Financial Issues; Health Issues; Housing Issues;

    Immigration Issues; Interpersonal Issues; Learning Disability;

    Marital Issues; Mental Health Issues; Psycho-emotional issues;Sexual Issues; Substance Abuse; Suicide, others.

    No. of needs No. of needs


    If accepted

    Reason for acceptance &


    If not accepted

    Referred to: Name of Organisation

    Name of Receiving Staff/


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    Section 5: Needs Assessment (if necessary by a multi-disciplinary team)

    Date created Reviewdate

    Staff in charge Name and Designation

    Other staff involved Name and Designation

    Functional Assessment Include ability to perform Activities of Daily Living such as feeding,grooming, bathing, dressing, toileting, mobility; Instrumental

    Activities of Daily Living (using the telephone, grocery shopping,

    preparing meals, doing housework and laundry); etc.

    Assessed by: (Name & Designation)


    Educational Background

    & Career History

    Include name of school, level and general academic performance

    for students. Include highest qualification and work history for


    Assessed by: (Name & Designation)Date:

    Medical History Include nursing needs, RAF status, place of medical follow up, etc

    Assessed by: (Name & Designation)


    Financial Profile Include reasons for financial difficulties, for e.g.alcoholism,certified permanently incapacitated; chronic illness; drug

    addiction; family relationship problems, gambling, imprisonment(prison/DRC); in debt or bankruptcy; irregular/not receiving

    maintenance; irregular employment; large family; low wages;

    non-contribution from other wage earners; physical/intellectual

    disability; poor budgeting; unemployment; others.

    -Family Means Test Information-Financial Assistance (if any)- Charges and Fees, including transport fees if any.

    Assessed by: (Name & Designation)


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    Section 5: Needs Assessment (continued)

    Psychological Profile Include general assessment for e.g. risk or history of abscondence,misconduct, violent behaviour, suicidal attempt, substance abuse,

    non-substance abuse, medical, others.

    Include observation of behaviour for e.g. aggression, task, anxiety,

    repetitive behaviour etc.

    Assessed by: (Name & Designation)


    Social History Include information of next of kin and caregivers, as well asinformation on formal and informal support network.

    Assessed by: (Name & Designation)



    Assessed by: (Name & Designation)


    Interests (e.g. hobbies)/

    Stated or KnownPreferences

    Assessed by: (Name & Designation)


    Section 6: Interpretive Summary

    Caseworkers Diagnosis

    Assessed by: (Name & Designation)Date:

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    Section 7: Care Plan

    Description (Aim) Date





    Goals and Measures Goal Type









    Partially -



    2. AchievedPartially -



    3. AchievedPartially -




    4. AchievedPartially -



    Action Plan/Strategies

    Progress NotesNote changes in client needs and circumstances and changes to care plan.

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    Section 8: Discharge PlanInclude role of client, family, community, other agencies and resources

    Date of closure Initiated by:

    Reason for closure

    Goals achieved

    Completion of Goals

    Caregiver satisfactionsurvey

    Is Survey Conducted; Level of Caregiver Satisfaction/ Comments

    Duration of stay (days)

    Organisation referred for


    Staff responsible forfollow-up

    Date of planned follow-


    Name of staff and

    contact details given to




    Clients signature/ Date

    Case managers

    signature/ Date

    Approved by:

    (Name, Designation and Signature, Date)

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    1. A Guidebook on Dementia Day Care Centres, (2002), Ministry of Health,


    2. CARF Behavioural Health Standards Manual 2006, Commission on

    Accreditation of Rehabilitation Facilities, United States of America.

    3. Guide on Intake and Assessment (2006), National Council of Social Services,Singapore

    4. Pal Abhimanyau, Individualised Care Planning Training Manual (2006), SocialService Training Institute, Singapore.


    5. Patrice L. Spath, Is Your Discharge Planning Effective? (2003) Brown-Spath &


    6. Knowing When To Share in Making It Happen, Working Together For

    Children, Young People And Families.