The Evidence Portal

Service utilisation and referrals

Flexible activity

In this activity, families are supported to access and use needed services. This includes:

  • organising and monitoring referrals to other services
  • promoting the use of other services and explaining why they are important
  • encouraging appropriate use of services (e.g. when to see your local GP or go to the ER)
  • enhancing the skills and confidence of clients to access other services

This supports families to access the support they need and to ensure the support they receive is right for them. This is especially important if the issues a family faces are outside of the expertise of a case manager and are best addressed by a specialist. 

How can it be implemented?

This activity is primarily embedded in existing home visits with a case manager. Ongoing contact between a case manager and family enables the case manager to check on the family’s progress and to ensure they have access to the services they need. 

The case manager works with the family to overcome any barriers to service utilisation (e.g. language barriers, time-poor, lack confidence, overwhelmed or confused by the system). They also provide ongoing support while a family is waiting for a referral to be accepted.

What should I consider when working with Aboriginal people and communities?

Aboriginal people and communities may experience particular barriers to service utilisation. A lack of cultural safety, racism and fear can prevent Aboriginal people from accessing essential services. Adopting a whole of organisation approach to cultural safety requires consideration of the policies and focus of the service, the physical location and environment, management and governance systems, human resources, and organisational processes. Cultural safety should be embedded into the organisation’s way of working and not be an add-on element of practice.

See the Cultural Safety and Wellbeing Evidence Review for more information.

Who is the target group?

This flexible activity has been implemented with a number of target groups. Key characteristics include:

  • Families assessed as high risk for child abuse and neglect
  • Teenage mothers at risk of maltreating their children
  • First time mothers 19 years old or younger
  • Low income couples or fathers
  • Parents with children under the age of 2 
  • Families in neighbourhoods with extreme poverty, unemployment and general economic distress

What programs conduct this activity?

  • In the Colorado Adolescent Maternity Program, home visitors coordinate referrals to social service agencies, and educational and vocational training programs. They also monitor and promote appropriate use of medical services. 
  • In the Family Connections program,  an automated resource directory and extensive network of in-kind and monetary resources were used to help families take advantage of existing community resources and, when not available, to use an emergency fund developed by Family Connections.
  • In the Hawaii Healthy Start Program, home visitors ensure families have access to needed services, including:  income and nutritional assistance, education, and services to address risks such as domestic violence, parental substance abuse, and poor mental health.
  • In the Healthy Families America program home visitors make referrals to community services as needed and screen and refer for developmental delay. They also encourage compliance with scheduled immunizations and well child visits, facilitate linkages to and encourage appropriate use of health care and community resources.
  • In the Home visiting program nurses and social workers are engaged in promoting social support systems, informal resources, and enhancing skills and confidence to access these resources.
  • In the Nurse Family Partnership program, nurses connect families with community health and human service agencies. Parents are urged to keep childcare appointments and to call the physician’s office when a health problem occurred, so the office staff can help them make decisions about whether office or emergency room visits are necessary. 
  • In the Supporting Father Involvement program, case managers refer families to other community services. 
  • In the Child FIRST program, case managers, with expertise in community resources, facilitate family engagement in community services. 
  • In My Baby and Me, coaches provide mothers with resource and referral information to address broader, individualized needs (e.g. housing, education, health care and insurance). 
  • The Parent Aide and Case Management Program organises referrals for substance abuse, childcare/respite and other community resources as needed.

Further resources

Last updated:

20 Feb 2023

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We acknowledge Aboriginal people as the First Nations Peoples of NSW and pay our respects to Elders past, present, and future. 

Informed by lessons of the past, Department of Communities and Justice is improving how we work with Aboriginal people and communities. We listen and learn from the knowledge, strength and resilience of Stolen Generations Survivors, Aboriginal Elders and Aboriginal communities.

You can access our apology to the Stolen Generations.

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