Module 12 – Integrated case management

12. Integrated case management

Introduction

Description:

This module provides professionals working with unaccompanied and displaced young people with a foundational understanding of integrated case management. It explores how to deliver safe, coordinated, and youth-centered support that addresses the diverse needs of refugee youth through collaboration, structured planning, and a trauma-informed approach.

Aim:

To equip staff with the knowledge, principles, and practical tools needed to implement case management that empowers young people, promotes safety, and builds pathways to long-term stability and independence.

Learning outcomes:

By the end of this module, participants will be able to:

Understand the core principles and purpose of integrated case management for displaced youth.
Conduct comprehensive and culturally sensitive needs assessments.
Coordinate services effectively across a multidisciplinary support network.
Maintain confidentiality and manage data securely and ethically.
Apply practical tools to track progress, set goals, and adapt support plans.
Recognize the central role of social work in case management.
Build and strengthen a support system around each young person through strong collaborations.

What is Case Management and why it matters

Case management is a collaborative, structured process that supports unaccompanied and displaced young people by assessing their needs, creating an individual development plan, and coordinating the services and professionals involved in their care. It is not a one-off intervention, but an ongoing cycle of assessment, planning, implementation, coordination, monitoring, and evaluation, always centered on the evolving needs and goals of the young person.

The goal of case management is to ensure that each young person receives comprehensive, consistent, and person-centered support. This includes addressing immediate needs such as housing, safety, and legal support, but also extends to long-term development areas like mental health, education, employment, and building life skills. Through this approach, young people are not seen as passive recipients of services, but as active participants in their own support journey. “User involvement” or “User participation”refers to the active participation of users – typically patients, service users, or clients – in the planning, implementation, and evaluation of services that affect them, particularly in areas like healthcare, social services, and education.

Understand the core principles and purpose of integrated case management for displaced youth.
Conduct comprehensive and culturally sensitive needs assessments.
Coordinate services effectively across a multidisciplinary support network.
Maintain confidentiality and manage data securely and ethically.
Apply practical tools to track progress, set goals, and adapt support plans.
Recognize the central role of social work in case management.
Build and strengthen a support system around each young person through strong collaborations.

Key Aspects of "User involvement" or "User participation" :

Empowerment: It emphasizes empowering individuals by giving them a voice in decisions that concern their own lives.
Co-creation: Services are designed and improved in collaboration with users to better meet their needs.
Democratic Principle: It is rooted in democratic values, where people have the right to influence public services they use.
Levels of Involvement:
- Individual level: Users participate in decisions about their own treatment or support.
- System level: Users or user organizations contribute to shaping policies and systems.

Examples:

In healthcare: A patient helps decide on their treatment plan in consultation with medical professionals.
In social work: A client is involved in shaping their support services.
In policy-making: User organizations sit on advisory boards or contribute to public consultations.

User participation is considered essential for creating more responsive, effective, and dignified services.

A strong case management system:

Builds a coordinated network of professionals around each young person (e.g., social workers, psychologists, legal advisors, educators).
Ensures communication and collaboration among the team, avoiding duplication of efforts and conflicting interventions.
Creates a shared understanding of the young person’s story, strengths, and challenges, leading to more effective and relevant support.
Helps professionals stay focused, allocate resources efficiently, and manage complex cases with greater clarity.
Empowers the young person by giving them a consistent point of contact (coordinator), a sense of stability, and greater control over their path forward.

In contexts where young people have often experienced fragmented care and institutional neglect, integrated case management offers a structure that is safe, responsive, and empowering. It creates a space where their needs are taken seriously, their rights are upheld, and they are supported to rebuild their lives step by step.

Holistic and Trauma-Informed Needs Assessments

Needs assessments are the foundation of effective case management. They are the first step in understanding the young person’s unique story, challenges, strengths, and aspirations. For unaccompanied and displaced young people, this process must be trauma-informed, respectful, and holistic, recognising the complexity of their past and the uncertainty of their present.

Many refugee youth have survived intense trauma, including war, family separation, exploitation, unsafe journeys, and systemic discrimination. Even once in safety, the effects of trauma do not disappear. In fact, trauma often resurfaces once immediate survival needs are met, and the young person finally has space to feel. This can manifest as withdrawal, low motivation, mistrust, emotional outbursts, or difficulty focusing, responses that can be misunderstood as resistance or non-compliance.

Professionals must approach the assessment process with patience, empathy, and cultural sensitivity. A trauma-informed lens helps us understand that behaviours are often survival strategies, and that healing and participation take time.

A holistic needs assessment should explore all core domains of the young person’s life:

Physical health
Mental health and emotional wellbeing
Housing and living conditions
Education and language needs
Legal status and documentation
Supportive relationships and community networks
Skills, interests, and goals for the future
Employment or vocational opportunities

The young person must be informed and involved throughout the process. Before making any referrals or sharing personal information with partner services (such as psychologists, schools, or legal aid), clear consent must be obtained. It is vital they understand:

What information will be shared
With whom
Why this is necessary for their support

This builds trust and transparency, helping them feel safe and more in control of their own journey. Ultimately, a well-conducted, respectful assessment is not just a tool for professionals – it is a first step in restoring agency, dignity, and connection for a young person who may have long been treated as a case number, not a person.

Coordinating Support: Building and managing a holistic support network

Effective case management for displaced youth depends not only on the skills of individual professionals, but on the strength of the support system surrounding the young person. This requires active coordination among a multidisciplinary team, clear role definitions, and the development of reliable referral pathways.

The key to successful coordination lies in clarity of roles. Each professional must understand:

What their responsibilities are,
Where their expertise begins and ends, and
When to refer to another professional

Trying to “do it all” can lead to burnout, miscommunication, and ineffective support. Instead, assigning clear roles ensures that the young person receives consistent, targeted help, while also protecting staff wellbeing.

The Role of the Lead case coordinator

The professional conducting the initial needs assessment (often a social worker or case coordinator) typically takes the lead in the case management process. They act as the central point of contact, ensuring that the young person’s evolving needs are understood, documented, and supported by a well-coordinated team. This lead role includes facilitating communication among all stakeholders, scheduling case reviews, and maintaining accountability.

Referral networks and external collaboration

No single organisation can meet all the needs of a young refugee. Building and maintaining a network of trusted external services: healthcare providers, legal aid, vocational training, mental health support, recreational activities, and community organisations – is essential. Referrals should be made with the informed consent of the young person, who must be prepared and empowered for the process. Building and maintaining a trusted professional network is vital. Wherever possible, staff should aim to work with services they know and trust – where they are confident that the young person will be treated with dignity, professionalism, and care. The relationships we build with other providers reflect back on the young person’s experience; if they feel disrespected or neglected by a referred service, it may also damage their trust in us.

Confidentiality and consent are key when sharing information between services. Professionals must always:

Share only relevant information, on a need-to-know basis.
Obtain informed consent from the young person, unless there is a safeguarding concern.
Explain clearly to the young person why the information is being shared and how it will help them.

In short, collaboration is not just about logistics – it’s about respect. Respect for the boundaries and contributions of other professionals, and most importantly, respect for the young person at the centre of it all.

Handling Complex or Crisis Cases

Some cases will require more intensive, immediate responses. When serious mental health concerns, safeguarding risks, or legal crises emerge, the case must be escalated. This involves activating internal safeguarding procedures or convening emergency team meetings. Having a protocol in place for escalation ensures that young people receive urgent care without delay.

Effective Communication and Information Sharing

Strong case coordination relies on timely and secure communication. Information relevant to the young person’s care must be shared ethically and responsibly among the support team. This includes regular updates, risk alerts, and progress notes. All shared information must remain within the designated case management team, and only the details necessary for effective support should be communicated. If a young person chooses not to disclose certain information, their decision must be respected—unless withholding that information poses a risk to their safety or that of others. All data should be stored securely, in line with data protection policies, and must be deleted five years after the case has formally closed. Using appropriate case management tools (such as digital systems or shared tracking templates) helps ensure everyone is aligned, duplication of effort is avoided, accountability is maintained, and the young person’s privacy is protected at all times.

Questions for self-reflection

Preparation Questions for Youth Workers

Self-reflection is an important part of this course because it helps participants think about their experiences and how they have grown. By taking time to reflect, individuals can better understand not only the current topic, but also their strengths, challenges, and what drives them. This process boosts self-awareness and encourages the use of what they’ve learned in real-life situations, supporting their personal and professional growth.

1. How do I understand my role in helping youth, and what can I do to make sure my responsibilities are clear?

2. How can I improve communication and teamwork with other professionals to make our support for young people more effective?

3. How do I make sure the young person’s needs and choices are the main focus when referring them to other services, and what can I do to help them feel empowered in this process?

4. Looking back at my experiences, how have I dealt with difficult or urgent cases, and what steps can I take to respond quickly and effectively in the future?

The Role of Social Work in Case Management

Social workers play a central and often anchoring role in the case management process for displaced youth. They are frequently the first point of contact when a young person reaches out for help, and are key to building trust, initiating assessments, and coordinating long-term support. Their ability to combine empathy with professional skill makes them essential in navigating complex support systems.

Building the Foundation of Trust

Young refugees often approach services with caution, shaped by past experiences of trauma, displacement, or institutional neglect. The social worker’s role is to meet them with empathy, cultural sensitivity, and active listening. Developing this initial rapport is not a one-time task but a continuous process. Trust is earned over time by demonstrating respect, consistency, and genuine care.

Core functions of Social Work in case management

Case Management: Social workers develop and oversee care plans tailored to each young person. They coordinate referrals, ensure follow-ups, and act as the central point of communication among service providers—healthcare professionals, educators, legal support, housing officers, and more.

Assessment and Planning: Using psychosocial tools, social workers conduct comprehensive needs assessments to understand the youth’s background, strengths, and risks. They then develop clear, individualised development plans, often grounded in SMART goals to guide long-term progress.
Crisis Intervention: When emergencies arise—whether related to safety, mental health, or housing instability—social workers respond with immediate action. They stabilise the situation, activate safeguarding procedures, and ensure appropriate support is in place.
Mental Health and Emotional Support: While social workers are not always trained therapists, they are skilled in offering emotional support, recognising symptoms of trauma, anxiety, and depression, and connecting youth to specialist services when needed.
Advocacy: Social workers help young people navigate complex bureaucracies, such as asylum processes, education enrolment, or accessing healthcare. They ensure that the young person’s voice is heard, their rights upheld, and their needs clearly communicated.

Collaboration and Teamwork: Social workers are rarely working alone. They engage in regular case coordination with psychologists, legal advisors, educators, and housing staff to ensure that each aspect of the young person’s life is addressed holistically. Knowing when to take the lead and when to delegate is a key professional skill.

Professional Competence and Self-Awareness

To be effective, social workers must also be self-reflective and aware of their professional limitations. Understanding when to consult, when to refer, and when to step back is vital for the safety of both the youth and the professional. Regular supervision, peer support, and ongoing training are crucial to maintaining both the quality of support and the well-being of the worker.

Confidentiality, Data Management and practical tools

Confidentiality is the foundation of trust in any supportive relationship, especially when working with young people who have already experienced displacement, trauma, and institutional oversight. When combined with effective tools and systems for data management, confidentiality becomes not just an ethical obligation but a practical means to ensure safe, consistent and coordinated care.

Why confidentiality matters

Young people must feel safe in order to share sensitive and personal information. As professionals, we have a duty to clearly explain how their information will be used, who will access it, and for what purpose. Consent should be informed, ongoing, and revisited when new referrals or services are introduced. Breaches of confidentiality, intentional or accidental, can seriously damage trust and put young people at risk.

Safe and effective Data Management

A secure and well-managed system for recording and storing information is essential for good case management. Online database platforms, such as Lamplight or other digital case management systems, allow for structured and password-protected documentation. These systems ensure that:

All professionals within the same organisation have access to up-to-date information.
Key information is not lost when staff change or services are transferred.
Sensitive content (such as legal or health matters) can be securely restricted.
The young person’s journey and support history is traceable and measurable.

Case-management-Consent-Form-

Consent Form

Ultimately, tools and systems are only as good as the people using them. A trauma-informed and rights-based approach must always underpin how we gather, store, and share information. When used effectively, these tools not only protect sensitive data but also empower professionals to offer better, more coordinated care.

Case Study

Case Study 1: Coordinated Support & Information Sharing

Title: Ahmed’s Network of Care

Background: Ahmed is a 17-year-old unaccompanied refugee from Sudan who recently arrived in your country after a long and traumatic journey through several transit countries. He is currently placed in supported accommodation and has been displaying signs of withdrawal, anxiety, and anger. He has no legal guardian and does not yet speak the local language fluently.

During your initial conversations, Ahmed discloses that:

He has persistent nightmares and struggles to sleep.
He suffers from chronic pain in his back and legs.
He dropped out of school at age 12 but wants to learn and work.
He has not yet applied for asylum because he does not understand the process.
He refuses to see a doctor because of a bad experience in a detention center.

Exercise:

Step 1: Identify the key areas of support Ahmed requires.

Step 2: List which professionals or services you would involve in his case (e.g., legal aid, psychologist, GP, interpreter, school enrollment office, cultural mediator).

Step 3: Describe how you would coordinate this multidisciplinary team:

Who would be the case lead?
How often would communication happen?
How would you manage overlapping responsibilities?

Step 4: Reflect on information sharing:

What kind of information needs to be shared?
How would you obtain Ahmed’s informed consent?
How would you ensure confidentiality while promoting collaboration?

Case Study 2

Case Study 2: Holistic and Trauma-Informed Needs Assessment

Title: Mina’s Hidden Burden

Background: Mina is a 16-year-old girl from Afghanistan who has been living in your supported accommodation facility for three weeks. She presents as calm and polite but avoids eye contact and never participates in group activities. She rarely leaves the house and has stopped attending her language classes after the first few days.

After building some rapport, she tells you:

She was separated from her family at the border and doesn’t know their whereabouts.
She had to stay alone in an informal camp for months where she was exposed to violence and hunger.
She wants to study but cannot concentrate.
She often feels numb, disconnected, and forgets things easily.

Exercise:

Step 1: Based on a trauma-informed approach, what elements would you include in her needs assessment?

What domains should be assessed? (e.g., mental/physical health, legal status, education, social support)
What tools might you use? (e.g., psychosocial scales, strengths-based interview questions)

Step 2: How would you build trust with Mina before the assessment?

What would you say or do to ensure she feels safe and in control of the process?

Step 3: Discuss next steps after assessment:

How would you prioritize her needs?
How would you involve her in the planning process?

Step 4: Reflection question:

How does trauma affect a young person’s ability to engage with services, and how can case coordinators adapt accordingly?

Exercise

Create a consent form aligned with your organisation’s policy

Objective: To enable professionals to reflect on and apply principles of ethical information sharing and confidentiality by developing a consent form that is clear, youth-friendly, and compliant with their own organisational policies and legal obligations.

Exercise:

Step 1: Based on a trauma-informed approach, what elements would you include in her needs assessment?

What domains should be assessed? (e.g., mental/physical health, legal status, education, social support)
What tools might you use? (e.g., psychosocial scales, strengths-based interview questions)

Step 2: How would you build trust with Mina before the assessment?

What would you say or do to ensure she feels safe and in control of the process?

Step 3: Discuss next steps after assessment:

How would you prioritize her needs?
How would you involve her in the planning process?

Step 4: Reflection question:

How does trauma affect a young person’s ability to engage with services, and how can case coordinators adapt accordingly?

Instructions for Participants:

Imagine you are preparing to support a new unaccompanied minor or refugee youth through your case management system. Before beginning, you need a consent form that:

Explains why and how their personal information will be used
Clearly outlines what they are consenting to (e.g. communication with other professionals)
States how long their data will be stored
Reflects both trauma-informed and rights-based approaches
Aligns with your organisation’s privacy and safeguarding policies

Your Task

Using the information we explored in this session as a model:

1. Review your organisation’s data protection and privacy policy
  - How long do you keep personal data?
  - Who is allowed to access the information?
  - In what circumstances is information shared without consent?
2. Create a one-page consent form that:
  - Uses simple, clear language appropriate for a young person aged 15–18
  - Covers data storage, sharing, safeguarding, and rights
  - Includes checkboxes and space for signatures
  - Can be explained verbally in under 5 minutes by a caseworker
3. Optional Add-on: Include a short verbal script a staff member might use when introducing the form to the young person.

Output:

Submit your one-page consent form as part of your case management toolkit
Be prepared to share your approach and rationale in a group discussion or workshop