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”To be continued …

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