Standards for public agencies

2020 Edition

Case Management (PA-CM) 4: Service Planning and Monitoring

Each individual or family participates in the development and ongoing review of a service plan that is the basis for coordination and delivery of appropriate services and support.
2020 Edition

Currently viewing: CASE MANAGEMENT (PA-CM)



Individuals and families who receive Case Management services access and use resources and supports that build on their strengths and meet their service needs.
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Service planning and monitoring procedures
  • Community resource and referral list
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records


PA-CM 4.01

An assessment-based service plan is developed in a timely manner with the full participation of persons served, and their family when appropriate, and includes:
  1. agreed upon goals, desired outcomes, and timeframes for achieving them;
  2. services and supports to be provided, and by whom; 
  3. possibilities for maintaining and strengthening family relationships and other informal social networks; 
  4. procedures for expedited service planning when crisis or urgent need is identified; and
  5. the individual’s signature.

Fundamental Practice

PA-CM 4.02

The agency works in active partnership with individuals and families to:
  1. directly provide, or arrange for necessary services;
  2. provide case coordination and monitoring of services; 
  3. ensure that they receive appropriate advocacy support; 
  4. assist with access to the full array of services to which they are eligible; and
  5. mediate barriers to services within the service delivery system.
Examples: Personnel can help to engage and motivate individuals and families in this process by demonstrating: 
  1. sensitivity to their needs and personal goals;
  2. a non-threatening manner;
  3. respect for their autonomy, confidentiality, sociocultural values, lifestyle choices, and complex family interactions;
  4. flexibility; and
  5. appropriate boundaries.


PA-CM 4.03

The agency maintains a comprehensive, up-to-date list of community programs and services, and information on how to access them.


PA-CM 4.04

Service monitoring includes:
  1. confirmation, usually within one or two working days, that a service has been initiated as scheduled;
  2. verification, usually within 15 working days, that the service is appropriate and satisfactory;
  3. follow-up every three months; and
  4. immediate response to any complaints or problems that develop in the delivery of services or with the individual or family receiving services.


The agency should tailor the type and frequency of service monitoring according to the needs of individuals and families, frequency and intensity of service provided, and frequency of contact with informal caregivers and cooperating providers.


PA-CM 4.05

The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly or more frequently depending on the needs of individuals and families, to assess:
  1. service plan implementation;
  2. the individual’s or family’s progress toward achieving goals and desired outcomes; and
  3. the continuing appropriateness of agreed upon service goals.


When experienced workers are conducting reviews of their own cases, the worker’s supervisor must review a sample of the worker’s evaluations as per the requirements of the standard.


PA-CM 4.06

Workers and persons served, and their family when appropriate:
  1. review progress toward achievement of agreed upon service goals; and 
  2. sign revisions to service goals and plans.