Guidelines for field staff to assist people living in ... - Housing NSW

SECTION 5: Interagency cooperationFor the majority of cases, a number of agencies and services will be involved inproviding support to persons living in domestic squalor. It is essential to ensure thatall service providers and agencies have a consistent approach to the person. Thiscould be arranged through a case meeting where agencies identify their roles andresponsibilities and a case manager is appointed.5.1 Coordination of services and development of Action PlansThe principal aims of cooperation between agencies are to:• identify a key worker or case manager responsible for ongoing liaison with theperson living in squalor• report on the initial assessment of the person and the proposed interventions• determine the course of action, agreed interventions, monitoring arrangementsand the individual’s responsible.Often the person who makes the initial contact with the client will assume the role ofcase manager. In some cases, the person who receives the referral will contactanother agency and request that this agency assume the coordinating role. Theservice that conducted the initial assessment might wish to convene a joint agencycase conference with representatives from the relevant services. However, it may bedifficult to coordinate a meeting quickly, therefore phone/e-mail communicationshould be considered as the next best option.Identifying the interventions required should be determined through a joint careplanning process, in consultation with the relevant agencies. Resource constraintsapply to human service agencies, and therefore the resources available will need tobe prioritised on a case-by-case basis.The case manager should complete a Squalor Action Plan (see Appendix 4), whichidentifies the actions to be undertaken, the person(s) responsible, and review dates.The case manager should distribute the Squalor Action Plan to all involved agencies.This will enable coordination of the services to be provided.5.2 Ongoing monitoringWhere cleaning of squalor is successfully completed and there is a substantialimprovement in the person’s living conditions, ongoing monitoring or follow-up is highlydesirable, as there is a high risk of recurrence.The service that provides ongoing monitoring will be determined by the following:• the need for a continuing role for the case worker• the nature of the intervention required• the need for other services, such as residential support services.Ongoing monitoring and follow up of the person could be provided by a number ofindividuals, including the general practitioner, mental health staff, NGOs, local council17