The Background
Case Management is still a relatively new concept in the UK and is not yet widely known or understood. In contrast, in the USA Case Management has long been valued as a method of ensuring effective outcomes for individuals who have sustained seriously disabling injuries.
The need for Case Management stems from the complex and potentially confusing overlap between the physical, social and psychological consequences of serious injury. Cost effective care and measurable outcomes have now become familiar terms to all those involved in rehabilitation in the UK and the introduction of Case Management is, in part, a means of achieving these. An effective Case Manager can focus the available resources on the individual, avoiding overlap of services, or the provision of unwanted help and equipment. Perhaps more common are the gaps that all too often occur when one organisation assumes, incorrectly, that another is providing a service, therapy or treatment. This problem is encountered time and time again, especially between the respective duties of the NHS and local authority to provide care.
The Case Manager acts as a hub, liaising with the numerous organisations concerned with the client's medical treatment, therapies, care, specialist equipment companies, and welfare benefits. Whilst some people prefer to make all of these arrangements themselves, many find it a struggle to understand how all of these services should fit together and the myriad of regulations behind them. This maze of services can be confusing to even the most organised of people. For those with an additional need for support, because of the severity of injury, age, lack of a close family network, or other background factors, an experienced person to turn to for help is essential.
The development of Case Management
Brain Injury Case Management has developed in the last decade to the extent that it has been recognised as an essential component to rehabilitation and reintegration. The growing number of brain injury Case Managers have set up their own organisation BABICM to ensure high standards and pursue the common aim of providing the best available rehabilitation support. Progress has been a little slower in the spinal cord injury world, even though many of those with SCI meet similar challenges to those with head injury.
Many of the Spinal Injuries Centres now employ Case Managers to assist with discharge planning and reintegration issues. The vital co-ordinating role between the numerous agencies and professionals involved in the patients care is gaining increasing recognition. Chris Freestone, the former Head of Case Management Services at the RNOH Stanmore and now of Independent Community Case Management, explains that "Spinal Injury Centres such as Stanmore involve the Case Managers in the process of rehabilitation from day one, when a Case Manager is allocated to the individual with an SCI to guide them through the inpatient phase to discharge and hopefully reintegration."
Unfortunately, the Spinal Injury Centres' Case Managers are unable to offer an intensive service post-discharge as their attention inevitably has to move on to their new patients. In the state sector the main responsibility will then usually pass on to a local authority social worker. Whilst there are some excellent social workers, there are also many who lack experience in working with those with SCI, or simply have so many people on their books it is impossible to provide quality and individual focused services. A further problem is that it may be necessary to put pressure on other departments of the same local authority, for instance, to provide suitable housing and adaptations. This may be difficult for a local authority employed social worker, whereas a Case Manager, working in the private sector, may be in a position to take a firmer line.
What services can a Case Manager provide?
Leading up to and then post discharge the Case Manager's job involves establishing a stable link between his client and the environment in which he lives. On the social side this has to take in the family, friends, and leisure activities. Different ways of socialising and new hobbies or sports may need to be identified and tried out. Employment prospects, study and training opportunities will often have to be considered. In some cases, the Case Manager may recommend appointing a local companion enabler to befriend and accompany the patient to training centres, colleges or on social outings. There may need to be discussions, or even advocacy, with tutors and potential employers, but before those stages are reached, the client has to be assisted to regain the best physical condition attainable and build up any loss of confidence.
Co-ordinating treatment from the specialist spinal injuries centre, local referring hospital, physiotherapist, GP and the myriad of other healthcare services is one of the key tasks. Where a private healthcare provider is involved, the Case Manager may also be able to assist in resolving any difficulties over the extent of cover, such as where it is alleged a condition has become "chronic" and consequently excluded from future funding.
Where care is needed, Case Managers recruit and train carers focusing on the needs of the client. The Case Manager will ensure health and safety legislation is complied with. Insurance can be arranged to offer protection against accidents, or even employment claims. The complexities of a PAYE system is often too much for the client and once again the Case Manager can take on this chore. They can establish a carer's rota and structure the daily and weekly routines. They supervise and help the carers both routinely and in situations that need trouble-shooting. The Case Manager can prove an invaluable intermediary in the close but sometimes difficult working relationships that can develop between client and carer.
Becoming aware of and then obtaining the full range of welfare benefits is one of the trickiest areas for those recovering from and living with SCI. The Disability Living Allowance forms for example are notoriously complex and lengthy. Other benefits, such as Industrial Injuries Disablement Benefit, are not well known. An experienced Case Manager can ensure all of the forms are correctly filled in, lodged and followed up if necessary. If, as a result, enhanced benefit payments can be received then the Case Manager may well have indirectly paid for his own services. Case Managers can advise and help the client obtain beneficial aids and equipment (such as adapted vehicles, wheelchairs, hoist, specialist furniture etc) and then use it to its full potential, arranging training where necessary.
The Case Manager will maintain accurate written documents of the client's case, monitor developments and step-in in emergencies or if programmes need to be revised, or extended. How much a Case Manager does for any one client is entirely their choice. If the client wants a cheaper minimal service, or simply to take on an aspect of their own arrangements, then the Case Manager will work to that brief. Case Management does not have to last for ever and can be used to "kick-start" a rehabilitation programme, with the client then taking over at a later stage once everything is up and running smoothly.
Paying for Case Management
Case Managers usually charge for their time on an hourly basis. These charges vary widely depending on region and the experience of the Case Manager, £50-60 per hour is a typical rate in central and southern England. Travel time can often form a major part of the Case Manager's bill, so it pays to ask whether they are relatively local to you, or can share travel time with other clients they may have in your area. If you require a substantial care package your Case Manager may instead propose a charging structure based on percentage of the care costs.
If you have been given the option of receiving direct payments for your care from your local authority, the funds can be applied towards Case Management. If not, instigating a transfer to direct payments may be a process that a Case Manager can help with. Unfortunately, payments from the Independent Living Fund can only cover pure care costs and do not extend to Case Management.
Spinal Injury specialist solicitors, such as Stewarts Law, at an early stage in the claim will push hard to arrange funding of Case Management, either through interim payments, or on occasions, by having the Defendants agree to fund the Case Manager's input directly. Providing it can show that the individual has a genuine need for Case Management services and gains a benefit from them, then the cost is likely to prove recoverable as part of the damages. Many of the Defendant insurance companies now try and take the lead on this issue, choosing, instructing and paying for Rehabilitation/Case Management consultants at an early stage. Whilst it is encouraging to see insurers taking an early interest in rehabilitation, and some of the services may be very useful, it should not be assumed that the injured person has no choice but to accept these services. This is a very personable decision and it is perfectly acceptable for the injured person to decide that they would like to choose their own Case Manager, or that they do not want a Case Manager at all at that time.
How do I find a good Case Manager?
Case Managers are usually drawn from paramedical professions: psychologists, occupational therapists, hospital discharge co-ordinators, and nurses. It is essential that they have clinical experience, not only of patients but also of co-operating with hospital staff, community services and voluntary resources. Case Management should be seen as an umbrella term as the role can vary enormously based on the needs of the client. Case Managers from differing backgrounds bring a variety of skills to various aspects of a client's needs be it care, housing, education, work or rehabilitation planning.
An increasing number of people are seeking the help of a Case Manager to assist them and their family with the many arrangements which they need to make consequent to spinal cord injury, to ensure that they get the best available rehabilitation, care services and support. However, many have found it difficult to identify candidates with suitable experience and define the role to be played by the Case Manager. Unfortunately there is still not any independent organisation representing spinal injury specialist Case Managers, as BABICM does for those involved in brain injury rehabilitation. Many of the members of BABICM (tel: 0700 222246) also provide spinal injury case management services. Personal recommendations, such as those from your treating spinal injuries centre, are often the best way of finding a good Case Manager.
As a Case Manager's role will involve getting to know the client well and providing long-term input, it is clearly important that the client is able to engage the services of someone whom they can get on with and generate a mutual relationship of trust and confidence.
Conclusion
An effective Case Manager can take the huge burden of organisation off the client and family, helping to normalise and restore their relationships. At the same time the Case Manager's expertise should ensure a better and more integrated range of services to the client.
The author, Julian Chamberlayne, is an Associate of catastrophic injury specialists Stewarts Law
SIA is including a new section, listing Case Managers experienced in SCI cases, in this year's Director of Personal Injury Solicitors which is due to be published in June 2003. Copies are available free to SCI people.