Continuity in everyday life
Ongoing Care & Case Management
When several people or services are involved, you should not have to hold every part of the plan together alone. A consistent point of contact can help you and your family navigate the practical steps before, during and after treatment.
Keeping the different parts of care together
Receiving good advice and putting it into practice are not always the same thing. When several professionals, appointments or practical responsibilities are involved, it can be difficult to know who is doing what or what happens next. Case management helps turn an agreed care plan into coordinated action.
The service begins with an assessment of your circumstances, goals, existing support and what needs organizing. You do not need to complete a VAYEMA program first. Coordination can sit alongside individual therapy, intensive outpatient care or treatment with professionals outside VAYEMA.
For the individual
Agreed support may include coordinating appointments, clarifying professional responsibilities, following up actions, arranging care-plan reviews and helping with transitions. The purpose is to make the plan manageable, not take control away from the person receiving care.
We identify what you would like help with, what you prefer to manage independently and when the arrangement should be reviewed. Existing doctors, psychiatrists or therapists can remain involved where appropriate, with communication based on your permission and relevant professional duties.
For families
Families may need help understanding recommendations, navigating services or deciding how to offer support without losing their own boundaries. A case-management arrangement can establish clear points of contact and agreed communication, alongside separate support for relatives where appropriate.
Family involvement and payment do not automatically give access to an adult’s clinical information. We clarify whose needs are being assessed, what may be shared and the limits of confidentiality. Family support can also be considered when the person of concern is not currently engaging in treatment.
When the first step into care feels difficult
Families sometimes contact us before their loved one is ready to accept support. Our Interventions service can help prepare a respectful conversation. If the person agrees to further care, case management can then help with the practical arrangements and communication between the professionals involved.
Through transitions and changes
A change in care can involve practical work as well as a clinical handover. Case management may help organize hospital or residential discharge, a reduction in treatment intensity, a move between locations or the return to work and daily responsibilities. The plan should identify the receiving professionals, agreed actions and a point at which the transition is reviewed.
Coordination around your everyday setting
Case-management meetings can be held online or in person at a professional’s practice or VAYEMA location. Home-based appointments may be arranged on demand where appropriate. We agree who will attend, the purpose of the meeting, information-sharing arrangements and any travel fees. Coordination can also connect care delivered in different settings.
Clear roles and clear boundaries
The clinical lead is responsible for assessment, treatment recommendations and clinical review within their scope. The case manager coordinates agreed actions and communication and brings clinical concerns to the appropriate professional. The two roles may sometimes be held by the same qualified person, but their responsibilities remain explicit.
Any ongoing arrangement should set out included work, contact hours, response expectations, cover, fees and review or cancellation terms. Ongoing care does not imply 24-hour availability. Coordination already included in another treatment program should not become an unexplained additional charge.