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The Case Management Approach
Dr Bill McKinlay
Neuropsychologist, Case Management Services LtdAssociate Editor, Brain Injury
bill.mckinlay@caseman.co.ukwww.caseman.co.uk
Long term problems after TBI
Physical/sensory/epilepsy
CognitiveEsp. Memory; attention; executive function
Emotional-behaviouralEsp. Reduced ability to regulate mood/temper,
apathy/tiredness, altered social behaviour
Most frequently reported problems after SHI - as observed by relatives (% reporting)
3m 6m12m
Slowness 86 69 67
Tiredness 82 69 69
Irritability 63 69 71
Poor memory 73 59 69Impatience 60 64
71Tension/anxiety 57 66
58Bad temper 48 56
67Personality change 49 58
60McKinlay, Brooks, Bond et al, J Neurol Neurosurg Psychiat, 1981
Long-term outcome Morton & Wehman (1995)
Review article - “Four main themes”
1 Significant decrease in friendships/social support - does not improve with time alone.
2 Lack of social opportunities - renewed and prolonged dependence on family.
3 Decrease in leisure activities.4 Anxiety and depression - prolonged and at high levels
(Q-scores rather than DSM-IV diagnosed).Brain Injury, 9, 81-92
Impact of behavioural problems on relationships (Wood et al, Brain Injury, 2005)
Studied 48 partners of people with serious TBI, 25 together, 23 divorced/separated
Presence of mood swings was particularly associated with strain in the relationship
Social isolation esp related to….AggressionPoor motivation for leisure activitiesFatigueObsessiveness
Frontal/dysexecutive effects
“Hot”
Reduced emotional regulation
“Cold”
Reduced ability to plan/sequence (incl “loss of set”)
Reduced drive/motivation
Self-awareness of deficits(Each area rated on a 4-point scale)
1. No awareness of deficit
2. Awareness of deficit
3. Awareness of functional implications of deficit
4. Ability to set realistic goals
FLEMING JM, STRONG J, ASHTON R Self-awareness of deficits in adults with traumatic brain injury: how best to measure? Brain Injury 1996, 10, 1-15
Jennie Ponsford et al: “Traumatic Brain Injury: Rehabilitation for Everyday Adaptive Living” (1995)
“Of all points in the rehabilitation process …. none is more critical than …. return to the community”
“Traditional rehabilitation service delivery models tend not to allow for community-based services over an extended period of time”
Roles for the Case Manager
Broadly speaking two-fold:
1. Facilitate community-basedrehabilitation (CBR)
2. Enable individual attain the best possible quality of life in the community
Advantages of community-based rehabilitation (CBR)· Relevance of rehab is clearer to clients - limitations often
masked in an in-patient unit.· Generalisation is more easily achieved - no need to ‘transfer’
skills at discharge.· Family understanding is increased - family members can help· Ready access to community facilities on which the client may
rely long-term - can be introduced during rehab· Travel and social skills are much more readily practised. · Cost advantages compared with inpatient rehabilitation.
Case-managed supported living
AIM:To maximise an individual’s independence and
support and maintain them in their own home, whilst: avoiding risk of deterioration and social isolation avoiding crises - inappropriate dependence on family who
become unable to cope
Case-managed supported living
This means….structure, structure, structure - e.g.college courses (hobbies/vocational) learning skills – e.g. computers, cooking – at home day centressocial clubsphysical activity - swimming/gymhousehold tasks, e.g. shopping (basics/planning)social activities, e.g. lunch/ pool/pub/gigs/clubshome-based hobbies like drawing/painting/craftsvoluntary work (e.g. teaching people with a disability)
Our TeamNeuropsychologists
Psychologists
Occupational therapists
Physiotherapists
Nurses
Social workers
Rehab assistants
Agency v other employment methodsPros Cons
Direct employment(client/family employ)
Consistency Loyalty
Maintaining cover difficult
Agency Resources (bank)AccountabilityAvoid conflict of interest
Staff variability?
Employment by case management company (also acting as nursing agency)
Maintain coverConsistent staffing?
Conflict of interestDifficulty with bankTime taken
How we work with agencies
Select agency
Recruit from within agency
Provide brain injury training to staff
Provide client support plan
Provide brain injury supervision to agency staff
Assessment/goal-settingPhysical/ADLBarthel ADL, Nottingham ExtendedCognitiveMMSE, ACE-RSocial engagementCommunity Integration QuestionnaireMood state/wellbeingHADSLife Satisfaction Questionnaire
Setting goalsClient-centred – may need to be carefully negotiated esp
where insight is limited
The Case Manager needs options in place – good access to (e.g.) memory training, anger management
Clear, measureable goals, regularly reviewed, are key to maintaining progress
Reducing care/dependency – i.e. increasing independence should be prominent, rather than just ‘managing’ present problems
Goal-settingGoal Grid
Online progress notesKept on serverAvailable to relevant team members in office or
remotely
Keep financial record sheets
Review completed sheets
Agree target amount to save
Achieve target for 1 week
Achieve target for 4 weeks
Discuss and review
Achieved 1.6.10
Achieved 1.6.10
Try to agree on 16.6.10
Referrals
Privately funded – usu. via personal injury settlements
May be instructed before or after settlement
May be referred by client or those acting on their behalf, incl:
solicitors/insurers
financial/welfare guardians
family members
We also have referrals from public sector
Studies show Q of L is greater:
If there are vocational opportunities
If there is access to leisure and social activities
With good social support and contact
Overall
… “being productive is a cornerstone in reaching a
high quality of life …”
Case study: “Derek”21, lives alone near familyInjured in childhood, never workedHit by a car, head injury with GCS 4/15; PTA>4 weeksDamage to R temporal lobeCognitively distractible, poor planning, memory problemsPhysically mobile, but some residual limitations (slower, pain,
can’t carry)Main problem is anger management – verbally and physically
aggressive in pastHas girlfriend (about 18 months) with learning difficulty; no
childrenHas a trust
Case study: “Derek”Referred well after settlement – family members struggling
to copeWhen our CM started, Derek had been receiving full
daytime care plus night ‘on call’, funded by SWD, BUT….He had struck staff members on 3 occasions in his carSWD risk-assessed – staff no longer to take him by carThis in part led to him refusing service – he had no service
for several weeks – heavily dependent on his mother
Case study: “Derek”Issues which were apparent included:Derek had been given no choice of providerNo structure to his week – he did nothingProvider said it was his “choice” – his ‘frontal’ problems
meant he found it hard to make a choiceThey did not support and encourage him with clear optionsThey did not prompt/encourage him to participate in
household tasks – so poor diet/takeawaysThey did not support him to plan shopping by first
reviewing what was in the cupboardIf he decided he didn’t want to open a letter it lay there –
he missed appointments – they did not prompt/encourage
Case study: “Derek”Derek’s mother had staff at her door regularly several times
a day asking her to come and deal with:Small issues (broken washing machine)Missed appointmentsAggressive behaviour usually verbal
Derek decided he did not want the same provider to continue because:“They don’t understand my head injury … taken me as far as
they can”He was unhappy at not using the car; bored at lack of things to
do; and he was unhappy that lack of service problem continued unresolved for 6 months
Case study: “Derek”NowHe has support 36 hours pw – 6hrs on 6 days – no night coverHe spends 2 nights pw at girlfriend’sMore active socially – bingo; pub (modest intake); looking to resume
swimmingNow shops and cooks – enthusiaticallyHopes to get a job at some time – CM is seeking supported
employment (he would like to be in hotel/shop type environment amongst people)
A plan is in place to resume car travel by stages after a full risk assessment
Mother is now not ‘on call’ and confident enough to take holiday breaks
No aggression
Costs in this case (over 8 months)
Cost of case management = £5565.97
Care at outset = 112 hours per week + “on call” at nightCosted at £12/hr = £1344pw = £46592 in 8 months(not counting “on call”)
Care now = 36 hours per weekCosted at £12/hr = £432pw = £14976 in 8 months
Saving = £31616 in 8 months
Family members as guardiansFamily members taking on these roles generally
receive no training.
Sometimes they have very fixed views about living/support arrangements.
Sometimes there is a conflict of interest (e.g. family members wanting to control the finances for motives of their own).
Case study: “Derek”1. Had to agree change of provider with SWD2. CM, SW, Psychologist discussed with Derek change of
provider and his expectations/obligations3. CM provided info on various possible providers4. Derek chose based on this information – he understood
they knew about head injury5. Met with their managers – and with CM planned a service
specification.6. Derek and CM interviewed existing staff who might be
suitable7. Derek chose staff with support – he was involved
throughout and has “ownership”
Case study: “Derek”1. CM did brain injury training with the staff2. Team leader and CM agreed and planned weekly structure
with Derek3. With prompting and support to choose he now:
Is involved in household tasks Needs less input Feels more in control Better anger control – no aggression since CM started Increased social activity/network There is also less dependence on his mother Car issue – graded programme which has been agreed with
Derek
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