Specific review scenarios: A change in needs is reported (either as part of a scheduled or unscheduled review)

An individual reports a change of circumstance to a condition we are aware of. Based on what we already know about the individual, this change was expected.

Scenario 3a: The individual has previously provided confirmation from a professional on this condition or good cause for not having confirmation from a professional has previously been established.

Here, we would not require confirmation from a professional. The case manager can go on and establish the individual’s new level of need and make a determination of entitlement.

Scenario 3b: The individual has multiple conditions and the confirmation from a professional that had been previously provided does not relate to the condition the reported change relates to.

Here, there are two possible outcomes:

Firstly, if the reported change is not likely to lead to a change in their award level, we would not require confirmation from a professional. The case manager can go on to make a determination of entitlement. If more detail on the individual’s new level of need is required, the case manager should take the steps set out in the section ‘Needing more detail to establish the new level of need’ section.

Secondly, if the reported change is likely to lead to a change in their level of award, we would want to see confirmation from a professional. For example, their level of award could change from the standard to the enhanced rate of the daily living component.

The change of circumstance reported by the individual could, for example, be a change that turns a previously minor condition with low to no impact on an individual’s level of award into a condition that now significantly impacts their level of entitlement.

 However, before reaching out for confirmation from a professional, case managers should discuss with a practitioner. It is possible the ‘new’ condition is a complication / progression from the original condition. If this is the case, confirmation from a professional is not necessary. Practitioners input should be sought before reaching out for confirmation from a professional.

Once either:

• confirmation from a professional has been provided 
• good cause for not having confirmation from a professional has been established or
• it has been established the new condition is linked or a likely progression given the previous condition

the case manager can go on and establish the individual’s new level of need and make a determination of entitlement. If more detail on the individual’s new level of need is required, the case manager should take the steps outlined above.

An individual reports a change of circumstance to a condition we are aware of. Based on what we already know about the individual, this change was not expected, for example because:

• we expected the condition or their needs to not change, or
• we weren’t expecting a change of this nature.

Previously, either:

• the individual has provided confirmation from a professional on this condition
• good cause for not having confirmation from a professional (i.e. the ‘one piece’) has been established.

Here, we would not require confirmation from a professional

The case manager should both:

• treat this as an inconsistency
• proceed with exploring inconsistencies in information to establish whether the inconsistency is relevant.

This could, for example, involve checking guidance or requesting a case discussion.

If the inconsistency is  relevant, the case manager should choose from the set of options below to explore and resolve it:

• Contact the individual to ask follow-up questions. Here, case managers must ensure that this phone call does not become, or feel to the individual like, a consultation, as consultations are carried out by practitioners only. For more details, see operational guidance on contacting individuals with follow-up questions.
• Choose the decision-making tool that is most appropriate/ most likely to provide the information they need.

There are a number of decision-making tools for case managers to use:

• Consulting guidance (decision making guidance, operational guidance, medical guidance)
• Case discussion
• Requesting supporting information
• Consultation

Supporting information:

• is one of several decision-making tools
• should not be the default step to take

when establishing the individual’s level of need.

Rather, the case manager should choose the action based on what’s most appropriate in the review at hand. As part of that, they should consider what’s best for the individual.

For example, a quick phone call to ask a follow-up question might be better than the individual having to

• collect supporting information from their wider support network
• wait a number of weeks until the case manager’s request for supporting information has been answered by the contact the individual has provided.

If the case manager decides that gathering supporting information is the most appropriate decision-making tool, they need to decide which source would be best-placed to provide the information they need. This can be a professional or a member of the individual’s wider support network.

Crucially, requesting supporting information should be done with the goal to more fully understand the individual’s new level of needs. The aim here is not to “verify” what the individual has told us.

Case managers should remember to follow the ‘collaborative information gathering’ approach where it is appropriate to gather supporting information at review. The individual might already have relevant supporting information at hand to help you make a determination meaning the Agency might not need to directly request it from a professional or the client’s support network. For more information, see the ‘Gathering Supporting Information’ chapter.

An individual reports a change of circumstance. The change is a new condition that Agency wasn’t previously aware of.

Scenario 5a: The new condition doesn’t change the individual’s entitlement.

Here, we would not require to see confirmation from a professional to confirm the individual’s new condition. We can make a determination based on what we have available.

It is possible that a case manager: initially thinks that the reported change will not impact on the individual’s level of entitlement, but further along the decision-making process understands that the individual’s award will change after all.

If this is the case, the case manager should move to Scenario 5b below and seek confirmation from a professional in relation to that condition.

Scenario 5b: the new condition is likely to impact on the individual’s level of award

Here, case managers should seek confirmation from a professional in relation to that condition. If that’s not possible, the case manager should see whether good cause can be established.

However, before reaching out for confirmation from a professional case managers should discuss with a practitioner. It is possible the ‘new’ condition is a complication / progression from the original condition. If this is the case, confirmation from a professional is not necessary. Practitioners input should be sought before reaching out for confirmation from a professional.

If more information is needed to understand the individual’s new level of need, the case manager should take the appropriate steps outlined above.