Case Management Plan Explained for Students (Easy Guide)

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CASE MANAGEMENT PLAN Patient/Client name: Felicity Walker Past Medical History: Nil significant Age: 32 Gender: Female Overall Patient Goals: 1. Safe and supportive antenatal, perinatal and postnatal care, and delivering a healthy baby safely 2. Gain confidence and manage anxiety related to parenthood, including building trust in Ross’s caregiving ability. 3. To ensure and prepare Ross in caregiving activities for the baby, considering his physical limitation by promoting his confidence and upholding the sense of a capable parent. 4. To access healthcare services for the holistic wellbeing of Felicity, the newborn and her husband, Ross. 5. To transform a safe and accessible home environment accommodating Ross’s limitations. Issues of concern Intervention Goal of intervention(s) Discipline responsible Priority (rank in order of priority, may have more than one ranked the same) Review date (e.g. hour, day, week, month, 3 months etc.) Overall health management and care coordination Ongoing physical health, medication consultation for eg. anxiety and referral to other health professionals To maintain overall health and ensure well- coordinated care General Practitioner High 2-4 weeks before the birth, in 1 week after birth and as required for ongoing support Coordinated antenatal care Regular appointments for birth planning and antenatal care and education sessions, care for new mom and baby for first few weeks after birth To promote maternal and fetal health and to prepare for parenthood, facilitate the smooth transition after birth Midwife High In 1 month until week 28, fortnightly 28-36 weeks, then weekly Anxiety and mental stress CBT, interpersonal psychotherapy, emotional regulation strategies and mindfulness To build resilience, support wellbeing and reduce anxiety Psychologist /mental health nurse High 1 month Emotional distress, stress related to Ross’s ability to care for a baby and its impact on their relationship provide emotional support, conduct a psychological assessment, navigate to the community support programmes To support emotional wellbeing, enhance the couple’s confidence in parenting, and connect them to supportive services Social Worker High In a week and then monthly or as required Pregnancy-related physical strain that may lead to back, hip, or joint discomfort Exercises, manual therapy like massage and joint mobilisation, and pain management To minimise pain, improve mobility, and support safe daily functioning during pregnancy. Physiotherapist Medium Fortnightly or as required Preparing Ross for parenting addressing his physical limitation Assess Ross’s physical ability, identify and recommend assistive devices and techniques for baby care To support inclusive and active parenting by recommending adaptive strategies or assistive devices Occupational Therapist Low In 2 months and follow up within 1 week after birth Introduction This person-centred and evidence-based case management plan (CMP) is developed in collaboration with interprofessionals for the 32-year-old Felicity, in her third trimester of pregnancy with her first child with her husband, Ross. She presented with emotional distress related to fears regarding her partner Ross’s physical limitations to co-parent because of his cerebral palsy. Rationale for Practitioner Inclusion and Their Roles A multidisciplinary team approach in Felicity’s care is effective in managing both clinical and psychosocial concerns that affect her, her partner, and their unborn child. Each health practitioner contributes evidence-based input to promote a safe and supportive transition to parenthood. General Practitioner (GP): The GP offers continuity across the perinatal and postnatal phases and acts as a first contact for Felicity by managing any emerging medical or psychological issues (Australian Institute of Health and Welfare, 2024). The GP’s involvement is vital to managing overall health, including medication and supplement management when required, and coordinating referrals to other professionals. Midwife: As the primary maternity care provider and central need of continuity of care, the midwife monitors Felicity’s physical and emotional well-being throughout her pregnancy (Faktor et al., 2023). Midwives have knowledge and training to support the pregnancy journey by providing care, advice and education, identifying and managing perinatal anxiety, and providing continuity of care to reduce maternal stress and increase satisfaction (Cummins et al., 2025). Midwives can refer Felicity for her increased level of anxiety or stress and any other health concerns so the GP can assess if Felicity should be referred to a psychologist or mental health nurse. Psychologist or Perinatal Mental Health Nurse: Felicity’s elevated anxiety and fear related to birth and concerns about Ross’s ability to care for the baby require early intervention. Untreated antenatal anxiety can lead to adverse outcomes such as a difficult childbirth, postpartum depression and weak mother-infant bonding (Lemmens et al., 2020). Her GP may refer her to a psychologist or mental health nurse who can offer cognitive-behavioural strategies and reassurance, considering complex emotional contexts by differentiating normal pregnancy-related worries and clinically significant anxiety disorders. The collaborative approach has been found more effective when psychologists and other health professionals, such as midwives and nurses, provide comprehensive support in reducing anxiety and stress during pregnancy (Lely Firrahmawati et al., 2025). Social Worker: The social worker can assist Felicity by providing emotional support to cope with the added stress related to Ross’s limitation in caring for the baby and navigating resources at the community level. They can provide mental health counselling, case management and behavioural interventions to assist Felicity and Ross to resolve the psychological and financial challenges and help mitigate role conflict between partners and link the couple with peer support networks for parents with disabilities (Noel et al., 2022). Social workers coordinate with the midwife, GP, and other health professionals to identify healthcare access barriers. Occupational Therapist (OT): The OT can assist Felicity in developing a daily routine, balancing self-care by planning the naps and taking rest and baby care by training her on how to lift the baby safely (Fernandes, 2018). Felicity is concerned about the impacts of Ross’s physical limitations when he takes care of the baby, despite the couple discussing it, and Ross’s willingness to take part. Occupational therapists are skilled in assessing the functions and adapting environments to assist in performing the tasks. It is crucial to provide customised solutions so that Ross can be empowered to attend to the care of his baby safely and Felicity can have confidence in her husband while he is performing the caregiving duties (Pituch et al., 2023). The OT can recommend aids (e.g., adapted change tables, bathing equipment) and train Ross in alternative techniques for completing the tasks related to baby care. Physiotherapist: The physiotherapist can be coordinated with a midwife and OT to help Felicity with an exercise program to reduce back pain or discomfort and prepare for childbirth, as well as postural advice (e.g. how to sit, lift, or sleep comfortably) and strengthening the pelvic floor muscles. The physiotherapist can also provide support to improve safety and prevent injury to Ross if he experiences increased musculoskeletal strain or falls risk with infant care tasks. Each team member focuses on their expertise while sharing a common goal to support Felicity and Ross in enjoying their parenthood confidently by managing the concerns. The GP can lead and manage person-centred care, coordinate referrals, interpret results from other professionals, and have broad clinical oversight. Felicity has discussed co-parenting with Ross but expressed intense anxiety regarding the practicability and safety of the postnatal care. There are three top priorities for the healthcare team: the first is to manage anxiety and emotional distress for the prevention of mental health worsening and foetal health resulting in preterm labour, low birth weight or other health issues (Chauhan & Potdar, 2022). The midwife can carry out mental health screening in routine antenatal checkups. The GP may refer her to a psychologist or mental health nurse to manage anxiety. Secondly, to ensure the well- coordinated antenatal care for a healthy pregnancy and safe childbirth, promoting the physical, emotional, and social domains. Thirdly, to support Ross in enhancing his abilities to fulfil his role as a parent and build the confidence in the couple for sharing the care of the newborn. A few health professionals are engaged as part of the team to manage Felicity’s case, which can develop conflicts regarding the relationship, the task priorities and the process (Orchard et al., 2022). For example, the overlap, such as the psychologist and social worker, manages the emotional issues. Additionally, the midwife and GP can have conflict in the priority regarding the emotional well-being of Felicity, referring to the psychologist. The delayed communication between the professionals can also create a conflict, resulting in additional efforts or unmet care. The team can communicate face-to-face or online meetings or communicate via email to discuss the goals and interventions for Felicity, clarifying the thie roles and responsibilities of each professional and escalating any concerns. Conclusion As the case coordinator, the GP can facilitate Felicity’s access to the person-centred health care services she requires during prenatal, perinatal, and postnatal care through a holistic approach. This CMP is an evidence based, safe, inclusive, and emotionally supportive journey to parenthood based on interprofessional collaboration

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