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Brain Injury Rehabilitation Directorate

Benchmarking a taxonomy for case management in the NSW Brain Injury Rehabilitation Program

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ACI Brain Injury Rehabilitation Directorate – Benchmarking a taxonomy for case management in the NSW Brain Injury Rehabilitation Program Page i

AGENCY FOR CLINICAL INNOVATION

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67 Albert Avenue

Chatswood NSW 2067

PO Box 699 Chatswood NSW 2057

T +61 2 9464 4666 | F +61 2 9464 4728

E [email protected] | www.aci.health.nsw.gov.au

Produced by: ACI Brain Injury Rehabilitation Directorate

SHPN (ACI) 160476 ISBN is 978-1-76000-539-9

Further copies of this publication can be obtained from

the Agency for Clinical Innovation website at www.aci.health.nsw.gov.au

Disclaimer: Content within this publication was accurate at the time of publication. This work is copyright. It may be reproduced

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permission from the Agency for Clinical Innovation.

Version: V10

Date Amended: 26/10/2016

© Agency for Clinical Innovation 2016

The Agency for Clinical Innovation (ACI) works with clinicians, consumers and managers to design and promote better healthcare for NSW. It does this through:

• service redesign and evaluation – applying redesign methodology to assist healthcare providers and

consumers to review and improve the quality, effectiveness and efficiency of services

• specialist advice on healthcare innovation – advising on the development, evaluation and adoption of

healthcare innovations from optimal use through to disinvestment

• initiatives including guidelines and models of care – developing a range of evidence-based healthcare

improvement initiatives to benefit the NSW health system

• implementation support – working with ACI Networks, consumers and healthcare providers to assist

delivery of healthcare innovations into practice across metropolitan and rural NSW

• knowledge sharing – partnering with healthcare providers to support collaboration, learning capability

and knowledge sharing on healthcare innovation and improvement

• continuous capability building – working with healthcare providers to build capability in redesign, project

management and change management through the Centre for Healthcare Redesign.

ACI Clinical Networks, Taskforces and Institutes provide a unique forum for people to collaborate across clinical

specialties and regional and service boundaries to develop successful healthcare innovations.

A key priority for the ACI is identifying unwarranted variation in clinical practice. ACI teams work in

partnership with healthcare providers to develop mechanisms aimed at reducing unwarranted variation

and improving clinical practice and patient care.

www.aci.health.nsw.gov.au

ACI Brain Injury Rehabilitation Directorate – Benchmarking a taxonomy for case management in the NSW Brain Injury Rehabilitation Program Page ii

Special working groups

Two working groups were made up as follows.

Phase 1: Margaret Doyle, Denise Young, Irena Gordon, Marion Fisher.

Phase 2: Margaret Doyle, Denise Young, Irena Gordon, Narelle Miller, Marion Fisher.

Margaret Doyle Rehabilitation Case Manager, Westmead Brain Injury Rehabilitation Service,

Western Sydney Local Health District

Denise Young Program Manager/Social Worker, Bathurst Health Service,

Western NSW Local Health District

Irena Gordon Program Manager, Illawarra Brain Injury Service, Port Kembla Hospital,

Illawarra Shoalhaven Local Health District

Narelle Miller Manager/Occupational Therapist, Dubbo Brain Injury Rehabilitation Program,

Lourdes Hospital, Catholic Healthcare

Marion Fisher Policy and Planning, Consumers and Paediatrics, Brain Injury Rehabilitation Directorate,

Agency for Clinical Innovation and Brain Injury Rehabilitation Research Group

ACI Brain Injury Rehabilitation Directorate – Benchmarking a taxonomy for case management in the NSW Brain Injury Rehabilitation Program Page iii

Abbreviations

Abbreviation Description

ACI NSW Agency for Clinical Innovation

ACI BIRP CM MoC NSW Brain Injury Rehabilitation Program Case Management Model of Care

BICM-T Brain Injury Case Management Taxonomy

BICM-PT Preliminary Taxonomy Tree for Brain Injury Case Management

BIRD Brain Injury Rehabilitation Directorate

BIRPCM Brain Injury Rehabilitation Program Case Management

CMSC Case Management Steering Committee (BIRD)

CMSA Case Management Society of Australia & New Zealand

LTCSA Formerly Lifetime Care and Support Authority, NSW. Now iCare.

NASW National Association of Social Workers [USA]

P/COs person and close others

SPs Service providers

SWG Special Working Group (of the CMSC)

ACI Brain Injury Rehabilitation Directorate – Benchmarking a taxonomy for case management in the NSW Brain Injury Rehabilitation Program Page iv

Contents

Section 1 Summary 1

Section 2 Phase 1: Mapping taxonomy to elements 2

Aim 2

Method 2

Results 3

Discussion and recommendations Phase 1 8

Section 3 Phase 2: Defining Core tasks and activities 9

Aim 9

Method 9

Results 9

Discussion and recommendations Phase 2 12

Section 4 Appendix 1 13

Section 5 References 17

Tables

Table 1 Mapped: BICM–PT (preliminary taxonomy tree) mapped to ACI BIRD CM MoC core elements 3

Table 2 Tasks and activities 10

Table 3 BIRPCM tasks and activities checklist 13

ACI Brain Injury Rehabilitation Directorate – Benchmarking a taxonomy for case management in the NSW Brain Injury Rehabilitation Program Page 1

The model of BIRP case management

documented a number of key elements,

tasks and activities that were able to be

benchmarked against a taxonomy (in a World

Health Organization [WHO] framework) for

brain injury case management.

This was achieved by the BIRD Case management

steering committee establishing a special working

group that used a 2 phased process to complete the

benchmarking and make recommendations.The special

working group acknowledges that this benchmarking

would not have been possible without this taxonomy

produced by a working group led by Sue Lukersmith

(University of Sydney and Lifetime Care & Support

Authority [LTCSA]).

Once the mapping was complete (phase 1), the steering

committee supported the need for the the working

party (identified) to complete a secondary piece of

work to expand the core elements from the mapping

phase into a set of tasks and activities (phase 2). This

resulted in a table that can be utilised as a checklist to

consistently describe the elements, tasks and activities

performed when providing BIRP case management. It

was recommended that the checklist be used as a tool

for supervision, workload management and

professional development.

Summary

Section 1


Section 2

Aim

Benchmark the ACI BIRP CM MoC core

elements with the brain injury case

management taxonomy (BICM-T)

(September – November 2015).

Method

The BIRD CMSC convened a SWG involving

Denise Young, Irena Gordon, Marion Fisher and

Margaret Doyle to explore the similarities and

differences between these two recent and separate

initiatives about case management in NSW for

people with traumatic brain injury.

As part of the process, to ensure there were no details

that were omitted, we considered the content of a

number of current resources/documents including:

• NSW Brain Injury Rehabilitation Program:

Case Management Model of Care, ACI, 2015 1

• BIRPCM (print) brochure, ACI, 2011 2

• National Standards of Practice, Case Management

Society of Australia & New Zealand (CMSA), 2013 3

• NASW Standards for Social Work Case

Management, National Association of Social

Workers (NASW) [USA], 2013 4

• National Skill Set for Effective Case Management in

Australia and New Zealand: Skills Workbook,

CMSA, 2015 5

• Preliminary Brain Injury Case Management

Taxonomy [BICM-T Beta2 ], LTCSA, 2014.6

A series of in-person and teleconference meetings were

held between September and November 2015. The

working group decided to start with the 10 core

elements of the NSW Brain Injury Rehabilitation

Program Case Management (BIRPCM), then match the

BICM-T terms to the 10 core elements. Overlap was

identified between concepts and terms for the BIRPCM

core elements with some of the BICM-T clinical

activities. For example, the BICM-T ‘coordination’ term

occurs in several BIRPCM core elements.

The final approach was discussed and consensus was

reached to start with BIRPCM core elements and map

BICM-T back to this.

The two documents used by the SWG to complete this

process were:

• NSW Brain Injury Rehabilitation Program Case

Management Model of Care (ACI BIRP CM MoC),

ACI, 2015 1

• The brain injury case management taxonomy

(BICM-T); a classification of community-based case

management interventions for a common

language, Lukersmith S, et al, 2015.7

Phase 1: Mapping taxonomy to elements

http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0006/289392/BIRP-Case-Management-MOC2.pdf

http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0006/289392/BIRP-Case-Management-MOC2.pdf

http://www.disabilityandhealthjnl.com/article/S1936-6574(15)00160-0/pdf





Results

See Table 1 for results.

The working group considered each core element

at a time. We reviewed the glossary and definitions in

the BICM-T, and agreed which parts of the taxonomy

matched the core element. It was noted that we

agreed that there was overlap with BICM-T concepts

and the way we have termed our elements. Some

clinic activities occur in different core elements. For

example, see BICM-T ‘coordination’, which overlaps

several core elements.

Core BIRPCM skills in documentation, person centred

practice and communication is implicit in the core task

elements. The BICT-T has focussed on the clinical role

and does not list the same non-clinical or organisational

type tasks.

Table 1 provides the outcome of the mapping of

similarities and differences between the two

primary documents.

It was then possible to identify four principles

underpinning all of the BIRPCM core elements.

Four Underpinning Principles

1. Engagement with person and close others

2. Documentation and reporting

3. Contextually-based rehabilitation

4. Progress towards autonomy/decision making.

In addition, a number of key organisational

requirements that are specific to the operation of

BIRPCM intervention and additional to the core

elements were identified. These include:

• team meetings

• audits, gathering statistics

• organisational requirements, including:

| quality of service – evaluation review and

revision, evidence-based practice,

guidelines, pathways, best practice,

professional development

| mandatory training.

Although these administrative, team work and

organisational tasks were not classified as a component

of the core elements, they each provide an area of

clinical practice that separately and together can be

time-consuming and reduce time available for direct

client and family activities.

¥ Preliminary Taxonomy Tree for Brain Injury Case Management (BICM-PT Beta 2) Throughputs (Interventions) appendix to: Lukersmith,

S., Fernandez, A., Millington, M., Salvador-Carulla, L. (2014). CM taxonomy nominal group, Discussion Paper 2: Towards a preliminary brain

injury case management taxonomy. Lifetime Care & Support Authority. September 30th 2014 6

§ The taxonomy (BICM-T) intervention tree table. (Lukersmith S, Fernandez A, Millington M., Salvador-Carulla, L., on behalf of the CM nominal

group (2015). (LTCSA internal document)) Contact: [email protected] 8

Table 1. Mapped: BICM–PT (preliminary taxonomy tree) ¥ mapped to ACI BIRD CM MoC core elements

BIRP core elements and definitions BICM-PT main actions §

BICM-T actions and related actions

1. Assessment

Complete holistic assessments at referral and subsequent key points.

Engage with client

Establish, develop and maintain a relationship with the client.

Accept referral

Ascertain capacity for decision making

Develop and maintain partnerships

Holistic assessment

Evaluate the client’s health condition, functioning, environment, behaviour, situation or need for intervention, to develop a comprehensive understanding of them, their perspective, and what is important to them.

Listen

Observe

Test hypotheses

Gather information from other sources Measures

mailto:[email protected]


BIRP core elements and definitions BICMPT main actions §


2. Goal setting and support planning

Develop client-centred, needs-based goals using clinical reasoning and in liaison with all relevant stakeholders.

Planning

Support the client to develop their individualised plan including setting goals and priorities, actions and responsibilities to achieve the goals and identify the supports needed (services and resources).

Prepare

Facilitate and support client to plan

Manage risks

Devise long-term support program

Finalise plan

Facilitate and support client planning to the extent possible or chosen by the client. This includes:

• identifying their goals and priorities

• planning steps and actions

• identifying resources, supports and barriers

• identifying longer term needs for support and resources (e.g. when case management needs to be reinstated, care, informal supports, network)

• formalising a process for monitoring maintenance of outcomes achieved

• reviewing for success, strategies and safeguards, weighing up the potential benefits, lessons learnt and what is important, the facilitators and barriers, while respecting and supporting client choice

• identifying client informed decisions, including plans for safeguards and responsibilities

• finalising the plan: reconsidering and revising the plan with the client considering all information from the client, scientific evidence and facts, professional experience, shared perspective and practical considerations. This includes managing documentation – recording information about an individual, group or environment.

3. Referral and liaison

Manage access to, and support for, non-BIRP services.

Coordination

Navigating and facilitating the access, management and cohesion of services and supports for the client.

Finding the most appropriate pathway through systems, services, resources and supports for the client given their context.

Consultation

Discussion with stakeholders to plan, improve and promote teamwork and achieve the agreed goals. Includes: meeting of multiple parties providing health service delivery or supports

Navigate

Activate links for client to supports and agencies

Collaborate and consult: integrate supports

Resolve issues with service provision

Build knowledge of local services and resources

Bridge


BIRP core elements and definitions BICM-PT main actions §


4. Monitoring and reviewing

Use an interactive process for the purpose of tracking client status during rehabilitation.

Holistic assessment

Includes: their strengths, capacity, performance and needs across domains in relation to health, participation in key life areas (education, work, social, cultural and civic life), wellbeing and the contextual barriers and facilitators. This also includes assessment for the purpose of identifying appropriate intervention(s) and planning interventions.

Listen

Observe

Test hypotheses

Gather information from other sources

Measure

Monitoring

Continuous acquisition of information to evaluate the client’s health condition, functioning, environment, behaviour or situation over a defined period to determine their progress, anticipate or identify problems, additional goals or activities, and modify their plan and services as appropriate.

Planning long-term supports

Identifying, promoting and supporting the client’s ownership and independence for management and coordination of their activities in key life areas to resolve problems, thereby reducing or ceasing their need for paid case management (to the extent possible and including the family or significant others).

This includes identifying the timing and manner for case management withdrawal; and supporting the client to perform case management activities for themselves including self-advocacy.

Prepare

Facilitate and support client to plan

Manage risks

Devise long-term support program

Finalise plan

5. Individual client work

Use clinical knowledge and expertise to develop support structures that maximise participation by building individual capacity in combination with environmental supports.

Training and skills development

Teaching, enhancing or developing skills through context-specific practice to client and stakeholders.

This includes providing information or reinforcing training strategies developed by others for skill development, e.g. memory or anger management strategies.

Emotional and motivational support

Providing client (family and others as appropriate) comfort, empathy or motivational support.

It includes supportive communication (without using theory based methods) to find strategies to solve or alleviate difficulties arising from their daily demands of life and situation; assisting, encouraging and reinforcing the client (and family as appropriate) to build independence, make decisions, exercise choice and responsibilities and take actions, and support the client and family’s adjustment to changed circumstances.

AdvisingRecommending a course of action to be followed to encourage a change of functioning, environment, attitude or behaviour in relation to health, goals or risks.

This excludes counselling and psychotherapy.




6. Advocacy

Work collaboratively with the person, the family and carers, and systems to achieve equity of access to needed resources.

Coordination


Consultation

Discussion with stakeholders to plan, improve and promote teamwork and achieve the agreed goals. Includes: meeting of multiple parties providing health service delivery or supports

Advocate

Navigate and link

Collaborate and consult Bridge




Education

Providing structured information to the client and stakeholders in a manner conducive to improving knowledge about matters relevant to the client’s health condition, medical, or rehabilitation treatment, functioning, situation or strategies.

7. Coordination

Managing the involvement of multiple stakeholders to work together as a team.

Coordination


Navigate and link

Collaborate and consult integrate supports

Resolve issues with service provision

Bridge Maintain feedback




8. Support of family and social networks

Work collaboratively with families and social networks to support clients in community living and social participation.




EngagementEstablish, develop and maintain a relationship with the client, family and carers.

Establish partnerships

Emotional and motivational supportProviding client (family and others as appropriate) comfort, empathy or motivational support. It includes supportive communication (without using theory based methods) to find strategies to solve or alleviate difficulties arising from their daily demands of life and situation; assisting, encouraging and reinforcing the client (and family as appropriate) to build independence, make decisions, exercise choice and responsibilities and take actions, and support the client and family’s adjustment to changed circumstances.

AdvisingRecommending a course of action to be followed to encourage a change of functioning, environment, attitude or behaviour in relation to health, goals or risks.

This excludes counselling and psychotherapy.

9. Education

Provide needs-based education to individuals, families/social networks and service systems.

EducationProviding structured information to the client and stakeholders in a manner conducive to improving knowledge about matters relevant to the client’s health condition, medical, or rehabilitation treatment, functioning, situation or strategies.







10. Community and service development

Investigate and influence policies and practices to ensure that service systems are responsive to individual and family needs.

Additional

A number of key indirect client tasks that are specific to the operation of BIRP case management services and additional to the core elements were identified. These include:

• client, family and team meetings

• insurer plans, report writing

• audits, gathering statistics

• professional development and organisational tasks.

Travel was an additional and important consideration for maintaining a contextually-based rehabilitation approach.

These were not classified as a component/core element of practice, although each of these tasks, separately and together, can be time-consuming.

Managing documentation and information between stakeholders. This involves recording information about an individual, group or environment, for example case conference decisions, progress reports, concerns and barriers, request for services, referral, linkage and liaison with service providers (SPs), agencies and clients.

Discussion and recommendations Phase 1

The SWG found that the main actions of the BICM-T were consistent with, and able to be mapped to the BIRD CM

Core Elements and Definitions (ACI BIRPCM MoC). There were some areas where the BICM-T overlapped more than

one core element (such as holistic assessment and training and skills development). There were some core elements

that did not have an equivalent in the BICM-T as they were considered to be out of the scope of the clinical

interventions (such as community and service development). Another BICM-T item, managing documentation, was

felt to be an underlying process (see 4 Principles, under Results for phase 1) for all elements of the BIRD CM.

The working group further saw the need for underlying skills and activities to provide CM with task descriptions.

This can then be considered for orientation, mentoring and quality monitoring. Further discussion about the tiered

information led to the second aim, and Table 2, recording required actions and tasks (phase 2) within each element

(see Table 2). Some were derived from BICM-T but others were extracted from the CM MoC.

It was also identified that there was potential to benchmark the core elements and taxonomy with Standard 4D,

Evaluation, in the CMSA National Standards of Practice for Case Management, 2013,3

but the CMSC agreed there would be no additional benefit at this stage.


Section 3

Phase 2: Defining Core tasks and activities

Aim

Identify specific tasks and activities for the

core elements of clinical practice described

in the ACI BIRP CM MoC (December 2015 –

January 2016).

Method

The SWG of the BIRD CMSC continued in the second

phase with an additional volunteer, Narelle Miller, with

Denise Young, Irena Gordon, Margaret Doyle and

Marion Fisher. From the further understanding reached

in the first phase, the working group attempted to

describe the tasks and activities required for each core

element. Further exploration of the tasks was

considered important to assist in identifying underlying

skills, activities and actions in relation to the BIRPCM

core elements, to provide more detailed case

management task descriptions.

Further resources used in this step, in addition to the

ACI BIRP CM MoC, consisted of:

• BICM-T Glossary 2015 9

• BICM-T Interventions Tree 2015. 8

An alternative link to the article with explanations/

videos is available on the University of Sydney, Projects

tab to aid understanding of the taxonomy tree and the

glossary. See Understanding Case Management page.10

Results

Table 2 provides the tasks and activities identified by

the SWG for each of the ten core elements of the ACI

BIRP CM MoC. It was thought that these tasks and

activities could then be considered in education and

training (orientation, mentoring, skill development) and

monitoring the quality of service delivery practices.

http://www.disabilityandhealthjnl.com/article/S1936-6574(15)00160-0/ppt


http://sydney.edu.au/health-sciences/cdrp/projects/taxonomy.shtml


Table 2. Tasks and activities

BIRP core elements and definitions Tasks and activities

1. Assessment

Complete holistic assessments at referral and subsequent key points.

“BICM-T: Evaluating the client’s health condition, functioning, environment, behaviour, situation or need for intervention in order to develop a comprehensive understanding of them, their perspective, and what is important to them.“ 6

1. Accept referral – criteria match to service and provider.

2. Ascertain capacity for decision making and identify who is the person responsible for the client.

3. Identify strengths and barriers (personal, family, contextual, community).

4. Listen and observe.

5. Use standardised and informal measures.

6. Gather information from all available sources to develop a comprehensive understanding of the person, their perspective and the resources available to them.

7. Document, report and provide feedback.

2. Rehabilitation planning and goal setting ‡

Develop client-centred, needs-based goals using clinical reasoning and in liaison with all relevant stakeholders.

“BICM-T: Supporting the client to develop their individualised plan including setting goals and priorities, actions, responsibilities to achieve the goals and identify the supports needed (services and resources).“ 6

1. Develop a comprehensive understanding of the person, how they see themselves, the injury and their future. This includes noting what’s important to them (life roles).

2. Note barriers and potential steps to achieving their valued outcomes (what will be worked on, for example Illawarra Brain Injury Service 5 questions).

3. Collaborate with the person, family/close others and team members in order to develop a framework for this person’s rehabilitation plans.

4. Understand what other resources and supports can be used.

5. Establish and maintain value, motivation and trust, for example establish some short-term successes, successful crisis management.

6. Compile and document the rehabilitation plan for the person, and the SPs.

7. Establish best communication and prompting style and strategies.



1. Source potential services and supports.

2. Investigate capacity of source.

3. Discuss options and collaborate with person, family/close others to match appropriate service to their circumstances.

4. Advocate for the individual (‘right service at the right time’), prioritising especially around choices, to achieve the person’s valued outcomes.

5. Use problem solving strategies around services and person’s needs.

6. Make initial introduction of all parties.

4. Review and monitor ∆

Use an interactive process for the purpose of tracking client status during rehabilitation.

1. Maintain contact and liaison with person, family/close others and service providers in order to monitor achievements and barriers.

2. Respond and modify rehabilitation plans as required with person, family/close others and service providers to maintain progress towards the valued outcome.

3. Facilitate, educate and support the person, family/close others to gradually take on self-management and responsibility.

4. Over time, the person’s journey, their values and desires, insight and risk taking may change, and this also is taken into account when responding or modifying a plan.

5. Demonstrate your own insight into your values, choices, risks etc. and those of the person and their context/’life environment’ – and do not be judgemental about their lifestyle choices and valued outcomes.

‡ Previously titled 'Goal Setting and Support Planning' in the BIRP CM MoC

∆ Previously titled 'Monitoring and reviewing' in the BIRP CM MoC



Use clinical knowledge and expertise to develop support structures that maximise participation by building individual capacity in combination with environmental supports.

1. Develop the person’s skills through teaching, training, practice, therapy, rehearsal in context with person, family/close others and service providers.

2. Reinforce therapy strategies implemented by other providers, to lead to a generalisation of skills.

3. Advise, recommend and provide motivational support for the person to work towards adjustment to change and achievement of their valued outcomes.

4. Support and facilitate problem solving, encourage and reinforce gaining information and making choices (empower independence as appropriate through person's progress).

6. Advocacy

Designed to achieve equity ofaccess to existing resources, bothindividual and systemic. Work collaboratively with the person, the family and carers, and systems to achieve equity of access to needed resources.

1. Lobby to achieve access for the person (‘right service at the right time’) to the best service for them at that time.

2. Represent the person’s preferences and choices in relation to achieving the person’s valued outcomes.

3. Educate and develop capacity of other services to provide appropriate services for this person.

4. Support and facilitate the person and close others to be able to lobby or plead on their own behalf.

5. Systems advocacy: provide education, collaborate and consult with relevant organisations around brain injury.

7. Coordination

Manage the involvement of multiple stakeholders to work together as a team.

1. Navigate and facilitate the access, management and cohesion of services and supports for the client.

2. Maintain cooperation and as examples, promote teamwork, convene meetings or encourage group emails – for the best outcomes for the person.

3. Communicate effectively with all others and keep updated with respect to ongoing strategies and therapy progress. This may be scripted and may also be about understanding barriers and risks. The more complex (behaviour, cognition or health) the tighter/closer the teamwork needs to be.

4. Collaborate and consult with all providers as plans, preferences and goals change.

5. Troubleshoot with all stakeholders/team members, including person, family/close others and service providers to resolve issues with service provision.

8. Support of family and social networks

Work collaboratively with families and social networks to support clients in community living and social participation.

1. Provide the person’s family and close others with empathy or motivational support.

2. Collaborate with the family/close others to sustain viable relationships with the person with the brain injury.

3. Be accessible for the person, family/close others and service providers to provide support and information in a timely way and using the preferred modes of communication.

4. Answer questions, source and provide information and options that can be understood by the person and family/close others to facilitate their choices and decision making.

5. Provide information at stages through the person’s recovery to improve knowledge about the person’s capacity to fulfil valued life roles and the responsibilities and risks associated with the person’s choices.

6. Facilitate the family and close others to adjust and adapt to changes in the roles and circumstances of the family.

7. Enable the family and close others to partner in the person’s rehabilitation using strategies and recommendations to optimise function and increase the person’s independence in valued life roles.


9. Education

Provide needs-based education to individuals, families/social networks and service systems.

1. Educate/develop capacity of other services to enable successful inclusion of person.

2. Provide education regarding brain injury in the community.

3. Provide structured information to the person, family, close others and those involved in the person’s care. Structured information would also be provided for those people in Core Elements 5: Individual client work, and 8: Support of family and social networks.∞


Investigate and influence policies and practices to ensure that service systems are responsive to individual and family needs.

1. Address gaps in availability and access to suitable supports or services outside of the BIRP (for example men’s shed, respite, recreational groups and accommodation support).

2. Be aware of and respond to legislative changes that impact on the people that we work with and our services such as LTCSA, National Disability Insurance Scheme (NDIS) and the National Injury Insurance Scheme (NIIS).

3. Review our capacity and services in response to changes in workload and needs and feedback from consumers and young adults transitioning to adult services.

Discussion and recommendations Phase 2

Following tabling and description of the draft report (version 4) at the ACI BIRD CMSC, the Committee discussed

the findings. There was recognition of the potential value of the tasks and activities in supervision, professional

development, education and training (orientation, mentoring, skill development) and monitoring the quality of

service delivery practices.

There was discussion regarding the use of the checklist as an audit tool, but there was initial reluctance around the

time burden. It was agreed, however, that clinical validation at a local level was a higher priority. It was agreed that

this could be achieved in a staff meeting, and where desired a local strategy or objective could be considered at the

service level.

There was also acknowledgment that there may be tasks that were not identified in this initial work. Feedback

about this also would be valued and considered for future versions.

Additional columns were added to Table 2 to create a checklist as required (see Appendix 1, Table 3). Formatting

as landscape did not reduce the number of pages but could be used if preferred.

Future considerations included:

• discussion point for caseload review/supervision

• audits

| at service checklist level or against other records

| comparative audits – for example compensable versus non-compensable, or ‘old client’ versus new

(less than 3 months)

| apportion time for these tasks

| additional use could include a self-rating of ‘how well’, ‘how often/much’ for each task

• benchmarking, for example against LTCSA case management approval criteria.

∞ Numbers refer to the titles as described of the BIRP Core Elements and Definitions


Appendix 1

Section 4

Table 3. BIRPCM tasks and activities checklist

BIRP core elements and definitions tasks and activities Check Additional comments

1. Assessment

Complete holistic assessments at referral and subsequent key points

1.1 Accept referral – criteria match to service and provider.

1.2 Ascertain capacity for decision making and identify who is the person responsible for the client.

1.3 Identify strengths and barriers (personal, family, contextual, community).

1.4 Listen and observe.

1.5 Use standardised and informal measures.

1.6 Gather information from all available sources to develop a comprehensive understanding of the person, their perspective and the resources available to them.

1.7 Document, report and provide feedback.

2. Rehabilitation planning and goal setting

Supporting the client to develop their individualised plan including setting goals and priorities, actions and responsibilities to achieve the goals and identify the supports needed (services and resources)

2.1 Develop a comprehensive understanding of the person, how they see themselves, the injury and their future. This includes noting what is important to them (life roles).

2.2 Note barriers and potential steps to achieving their valued outcomes (what will be worked on, e.g. IBIS 5 questions).

2.3 Collaborate with the family, close others and team members in order to develop a framework for this person’s rehabilitation plans.

2.4 Understand what other resources and supports can be used.

2.5 Establish and maintain value, motivation and trust, e.g. establish some short-term successes, successful crisis management.

2.6 Compile and document the rehabilitation plan for the person and the service providers.

2.7 Establish best communication and prompting style and strategies.





3.1 Source potential services and supports.

3.2 Investigate capacity of source.

3.3 Discuss options and collaborate with P/CO to match appropriate service to their circumstances.

3.4 Advocate for the individual (‘right service at the right time’), prioritising, especially around choices, to achieve the person’s valued outcomes.

3.5 Problem solving around services/person’s needs.

3.6 Initial introduction of all parties.

4. Review and monitor

Use an interactive process for the purpose of tracking client status during rehabilitation

4.1 Maintain contact and liaison with person, family close others and service providers in order to monitor achievements and barriers.

4.2 Respond and modify rehabilitation plans as required with P/CO/SP to maintain progress towards the valued outcome.

4.3 Facilitate, educate and support the person, family/close others to gradually take on self-management and responsibility.

4.4 Over time, the person’s journey, their values and desires, insight and risk taking may change. This also is taken into account when responding or modifying a plan.

4.5 Demonstrate your own insight into your values, choices, risks etc. and those of the person and their context/life environment. Don’t be judgemental about their lifestyle choices and valued outcomes.


Use clinical knowledge and expertise to develop support structures that maximise participation by building individual capacity in combination with environmental supports

5.1 Develop the person’s skills through teaching, training, practice, therapy and rehearsal in context with P/COs and SPs.

Excludes counselling or psychotherapy

5.2 Reinforce therapy strategies implemented by other providers, to create a generalisation of skills.

5.3 Advise, recommend and provide motivational support for the person to work towards adjustment to change and achievement of their valued outcomes.

5.4 Support and facilitate problem solving, encourage and reinforce gaining information and making choices (empower independence as appropriate through person’s progress).



6. Advocacy

Work collaboratively with the person, the family and carers, and systems to achieve equity of access to needed resources

6.1 Lobby to achieve access for the person (‘right service at the right time’) to the best service for them at that time.

6.2 Represent the person’s preferences and choices in relation to achieving the person’s valued outcomes.

6.3 Educate and develop capacity of other services to provide appropriate services for this person.

6.4 Support and facilitate the person (P/CO) to be able to lobby or plead on their own behalf.

6.5 Systems advocacy: provide education, collaborate and consult with relevant organisations around brain injury.

7. Coordination

Manage the involvement of multiple stakeholders to work together as a team

7.1 Navigate and facilitate the access, management and cohesion of services and supports for the client.

7.2 Maintain cooperation and promote teamwork, convene meetings, encourage group emails etc. for the best outcomes for the person.

7.3 Communicate effectively with all others (P/CO/SP) and keep updated with respect to ongoing strategies and therapy progress. This may be scripted and may also be about understanding barriers and risks. The more complex (behaviour, cognition or health) the tighter/closer the teamwork needs to be.

7.4 Collaborate and consult with all providers as plans, preferences and goals change.

7.5 Trouble shoot with all stakeholders/team members (including P/COs) to resolve issues with service provision.

8. Support family and social networks

Work collaboratively with families and social networks to support clients in community living and social participation

8.1 Provide the person’s family and close others with empathy or motivational support.

8.2 Collaborate with the family/close others in order to sustain viable relationships with the person with the brain injury.

8.3 Be accessible for the family/close others to provide support and information in a timely way and using the preferred modes of communication.

8.4 Answer questions, source and provide information and options that can be understood by the person’s family and close others to facilitate their choices and decision making.

8.5 Provide information at stages through the person’s recovery to improve the close other’s knowledge about the person’s capacity to fulfil valued life roles and the responsibilities and risks associated with the person’s choices.

8.6 Facilitate the family and close others to adjust and adapt to the changes in the roles and circumstances of the family.

8.7 Enable the family and close others to partner in the person’s rehabilitation using strategies and recommendations to optimise function and increase the person’s independence in valued life roles.



9. Education

Provide needs-based education to individuals, families/social networks and service systems

9.1 Educate/develop capacity of other services to enable successful inclusion of person.

9.2 Provide education regarding brain injury in the community.

9.3 Provide structured information to those involved in the person’s care. Applies also in 5: Individual client work and 8: Support of family and social networks.


Investigate and influence policies and practices to ensure that service systems are responsive to individual and family needs

10.1 Address gaps in availability and access to suitable supports or services outside of the BIRP (for example, men’s shed, respite, recreational groups and accommodation support).

10.2 Be aware of, and respond to, legislative changes that impact on the people that we work with and our services such as LTCSA, NDIS, NIIS.

10.3 Review our capacity and services in response to changes in workload and needs and feedback from consumers and young adults transitioning to adult services.


References

Section 5

1. NSW Agency for Clinical Innovation. NSW Brain Injury Rehabilitation Program: Case Management Model of Care. Sydney: NSW Health; 2015. 76p. Available from: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0006/289392/BIRP-Case-Management-MOC2.pdf.

2. NSW Agency for Clinical Innovation. Model of case management in the NSW Brain Injury Rehabilitation Program (BIRP) [brochure]. Sydney: NSW Health; 2015 2p. Available from: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/292824/BIRP-case-management-diagram-flier.pdf.

3. Marfleet F, Trueman S, Barber R. National Standards of Practice for Case Management. 3rd edition. Cairns: Case Management Society of Australia & New Zealand; 2013. 39p.

4. National Association of Social Workers [USA]. NASW Standards for Social Work Case Management, Washington, DC: National Association of Social Workers; 2013. 62p.

5. Marfleet, F. National Skill Set for Effective Case Management in Australia and New Zealand: Skills Workbook. Cairns: Case Management Society of Australia & New Zealand; 2015. 96p.

6. Lukersmith S, Fernandez A, Millington M, Salvador-Carulla L, Discussion Paper 2. Towards a preliminary brain injury case management taxonomy, September 30th 2014. Sydney: Lifetime Care & Support Authority; 2014.

7. Lukersmith S, Fernandez A, Millington M, Salvador-Carulla L. The brain injury case management taxonomy (BICM-T); a classification of community-based case management interventions for a common language. Disability and Health Journal. 2016; 9: 272-280. DOI: http://dx.doi.org/10.1016/j.dhjo.2015.09.006. Available from: http://www.disabilityandhealthjnl.com/article/S1936-6574(15)00160-0/pdf

8. Lukersmith S, Fernandez A, Millington M, Salvador-Carulla L. (Supplement: The Taxonomy Tree) The brain injury case management taxonomy (BICM-T); a classification of community-based case management interventions for a common language. Disability and Health Journal. 2016; 9: 272-280 [presentation]. Disability and Health Journal. 2016; Supplement. Available from: http://www.disabilityandhealthjnl.com/article/S1936-6574(15)00160-0/ppt

9. Lukersmith S, Fernandez A, Millington M, Salvador-Carulla L. (Appendix 3 Glossary) The Glossary: A preliminary taxonomy of community-based case management in brain injury (BICM-PT). Disability and Health Journal. 2016; 9: 272-280, Appendix 3. Available from: http://www.disabilityandhealthjnl.com/cms/attachment/2051606651/2059398580/mmc3.docx.

10. University of Sydney. Understanding Case management page. Sydney: University of Sydney; 2016. Available from: http://sydney.edu.au/health-sciences/cdrp/projects/taxonomy.shtml

https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0006/289392/BIRP-Case-Management-MOC2.pdf



https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/292824/BIRP-case-management-diagram-flier.pdf



http://dx.doi.org/10.1016/j.dhjo.2015.09.006

http://dx.doi.org/10.1016/j.dhjo.2015.09.006







http://www.disabilityandhealthjnl.com/cms/attachment/2051606651/2059398580/mmc3.docx





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