Case management
Case management and the many rehabilitation and recovery pathways.
When a person has an TBI there are many different rehabilitation pathways depending on the cause of the TBI and point in the life span the injury occurred and the person's circumstances. For example:
- An adult with a serious traumatic brain injury could have the following pathway: Hospital Brain Injury Rehabilitation Unit; discharge to supported accommodation; community rehabilitation services
A successful rehabilitation process weaves the following four strands together into a unified whole.
- The person's injury and their personal journey of recovery and rehabilitation outcomes
- The rehabilitation core activities/interventions that wrap around the person on their journey
- Typical service settings & pathways through them
- Typical funding pathways for rehabilitation and support services.
Case managment is often a key ingredient in weaving the strands together.
Goal
The overall goal of case management for people with TBI is to enable them to become as independent as possible.
The goal is for the person to return to their previous abilities, activities and way of life as much as they possibly can. It means enabling the person to live with their remaining abilities and develop strategies to enable them to compensate and overcome new difficulties.
Phases of case management
Typical phases of case management are:
- engagement and relationship building;
- information collection and assessment;
- planning and prioritisation of needs;
- allocation, development and negotiation of resources;
- implementation of a plan;
- monitoring of the plan; and
- review of the plan, case closure or reassessment.
The nature, intensity and duration of each of the case management phases will vary for each individual.
When working with people with TBI there are ideas tools and resources that may be especially useful. See the tabs for each phase.
Engagement and relationship building
The purpose of engagement is to nurture and develop a professional and trusting relationship with the client and their family and/or carer.
Effective engagement is achieved through active listening, and creating a safe, trusting environment.
In working with people with TBI it may be useful to review what makes the person with TBI unique. It may also be useful to review what are common emotional and relationship responses to TBI
Information collection and assessment
This includes identifying the person's strengths, assets and resources, and life areas the person wants to change.
Assessment includes identifying difficulties the person may be experiencing in areas of their life including personal and community relationships, their health, and environment. It is also appropriate at this time to bring together other sources of information such as verbal and written reports, to help build a picture.
Planning and prioritisation of needs
Planning is a holistic ongoing process, occurring in a variety of ways including informal and formal elements. It explores the interests and life circumstances of the person.
The development of any plan must be realistic and take into account the ability of those involved to work towards meeting the identified goals.
A number of initial goals may be identified that address short term and immediate issues relevant to the person with a disability. However, a holistic plan is future focused.
Implementation
Implementation of any plan can occur at three significant levels. They are;
1. the person with a disability,
Once the plan has been developed in collaboration with the person with a disability, goals should be prioritised, desired outcomes identified and strategies agreed on, taking into account the range of informal and formal enablers and constraints
2. family, friends, supporters and community
This may involve assisting family, friends and supporters to build knowledge, skills and resources that will support them and the person with a disability to meet the identified outcomes
3. intervention at a systems level
The case manager working at this level will undertake a range of tasks. For example,
i. analysing the strengths and constraints of the service systems.
ii. selecting strategies to improve systems
iii. assessing the effectiveness of strategies and continuing to revise desired outcomes and strategies.
The Toolkit B. Working Together Promoting Independence provides practical tips and tools for working with people with TBI.
Monitoring
Monitoring occurs at a number of levels and is an ongoing process. It identifies the effectiveness and relevance of goals identified and the timeliness and effectiveness of strategies, focusing on elements of the overall plan.
Critical to the integrity of this process is the perceived effectiveness by the person being case managed. Some responsibility for monitoring also rests with the family and support networks of the person being case managed who have been involved in the planning process.
In working with people with TBI the section on Monitoring provides tips on how to ask good questions and how to support the person with TBI in reviewing their situation.
Review
The review process is distinguished from monitoring in that it should reflect on all elements of the plan including the goals, strategies and outcomes. However, as with the monitoring process, it should also be driven by, and be inclusive of, the perceptions of the effectiveness by the person being case managed.
A good review will be characterised by the following elements;
- what has been achieved to date? For example has the person been more involved in the community; do they have more confidence; do they see their future differently?
- do the achievements relate to the original goals set?
- did anything change along the way such as a change in personal or family circumstances or health status?
- what were the most significant positive outcomes for the person with a disability?
- how have the outcomes made a difference?
- what wasn't achieved?
- how can these points be addressed in future planning activities?
Responses to all the above questions need to be taken into account for subsequent planning. Collaboratively looking at the whole plan to see if the identified goals have been achieved, and if what the person with a disability wanted has occurred, is also required. They identify achievements, fulfilment and areas requiring more attention and new or emerging issues, concerns or aspirations.
In working with people with TBI the section on Monitoring that provides tips on how to ash good questions and how to support the person with TBI in reviewing their situation.
Closure
Closure can be influenced by two key variables. First, is the outcome of discussing the ongoing goals of the person. This includes the capacity of all parties to remain involved and the willingness of the person and their networks to maintain contact with the case management practitioner.
The second key variable is the organisational constraints on the practitioner, influencing their capacity to maintain involvement with the person with a disability. When the organisation requires closure, despite the person with a disability wishing to remain in contact, the practitioner has several ethical obligations that should be supported by the organisation. This may involve ensuring that other supports, both formal and informal, have the capacity and intent to provide ongoing support.
With people with TBI who have damage to the frontal lobe
People who have damage to the frontal lobe of the brain often have difficulty with
- planning
- coordinating
- initiating
One of the consequences of this is that often people who have frontal lobe damage are also the ones who need ongoing case management. In these situations the Case manager's roles is to act as their frontal lobe. The case management is likely to be episodic as it will be needed when new situations will continue to arise in his life - moving house, changing job, getting sick.
People with frontal lobe damage will need episodic case management for life.
To provide an appropriate service case management services need to ensure there are policies and procedures in place so that a person can re-enter case management quickly. If case management doesn't happen quickly when needed the person's life may spiral out of control.
Goal
The overall goal of case management for people with TBI is to enable them to become as independent as possible.
The goal is for the person to return to their previous abilities, activities and way of life as much as they possibly can. It means enabling the person to live with their remaining abilities and develop strategies to enable them to compensate and overcome new difficulties.
Rehabilitation process
Rehabilitation is the process of ongoing recovery.
With people with TBI the process of rehabilitation experienced by each person is unique. Just as a brain injury is unique, the type of rehabilitation program the person is engaged in is uniquely tailored to target individual needs. Rehabilitation addresses specific areas of physical difficulty, thinking or cognitive processing, perception, social skills and relationships. It also addresses broader areas of returning to work, getting about in the community, and adjusting to changes a person may experience following brain injury.
With people with TBI rehabilitation is ongoing.
It may also be episodic - as new situations and opportunities arise.
Rehabilitation is based on working with the person to achieve things that matter to them. Therefore, for it to be successful, the individual needs to participate actively in the rehabilitation process. The type of rehabilitation offered needs to be meaningful and relevant to the person. This means the person, their culture, pre-injury lifestyle, family and environment are critical to ensuring the success of rehabilitation.
The person's abilities will determine how the person is able to participate in the rehabilitation process.
Where recovery to the person's pre-injury life pathway is not possible rehabilitation involves choosing another meaningful but different pathway to a life worth living.
With people who have damage to the frontal lobe
People who have damage to the frontal lobe of the brain often have difficulty with
- planning
- coordinating
- initiating
One of the consequences of this is that often people who have frontal lobe damage are also the ones who need ongoing case management. In these situations the Case manager's roles is to act as their frontal lobe. The case management is likely to be episodic as it will be needed when new situations will continue to arise in his/her life - moving house, changing job, getting sick.
People with frontal lobe damage will need episodic case management for life.
To provide an appropriate service case management services need to ensure there are policies and procedures in place so that a person can re-enter case management quickly. If case management doesn't happen quickly when needed the person's life may spiral out of control.
One case manager noted:
When everything is running smoothly the person can seem to be functioning well. They may hold down a job, be able to get themselves to and from work. But if their job role were to change or if they had to decide whether or not to sell a property they are no longer able to cope. Case management is needed at this point.
Working through emotions and relationships with the person, their family and friends
A person with an acquired brain injury has had a life before the injury. Unless they are very young when they had the injury they will remember the life they had. They will have experienced loss and grief.
The acquired brain injury may have effected their
- thinking skills - cognitive
- communication/language
- physical/sensory
- emotional/behavioural/personality.
These can impact on their emotions - e.g. they may have a period of depression, they may have some personality change.
These emotional changes caused by the brain injury are not mental illness.
In addition to experiencing these changes the person with the TBI has to respond to and come to terms with their new life situation.
They also have to deal with their family members and friends coming to terms with the changes in them.
Friends often can't understand the changed nature of the person that they used to know and so friends fall away (even though their friendship is still very important to the person with the TBI).
Emotional challenges for the case manager
It can be hard to get to know people with TBI - I need to give myself the time I need to do this.
Sometimes people with TBI can be abusive or aggressive or difficult to relate to in other ways. I need to not take this personally.
Gains with TBI clients can be slow in coming - I need to make sure I don't give up to soon. Or get caught in the disillusionment process.
Service providers are often not flexible enough for the needs of people with TBI. I will need to advocate on the behalf of people with TBI for services to be more flexible, change their policies to make them more appropriate. I may need to be ready for some fights.
