Case Management is a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates the options and services required to optimise an individual’s health and well-being, using advocacy, communications and available resources to promote quality, cost-effective outcomes in the individual’s best interest.
Our service is underpinned by the principle that the Case Manager has a Duty of Care towards the client (the person with a brain injury), irrespective of who funds the care.
The scope of Case Management intervention varies according to client's needs, wishes and values, but always includes establishing a therapeutic alliance with all those involved and working towards agreed outcomes. Specific objectives may include setting up a home-based rehabilitation programme - including identifying and commissioning suitable therapists; accessing in-patient rehabilitation; establishing and supervising a Support Work team; arranging training for Support Workers and Families; managing employment and payroll of Support Workers; assistance with re-housing; facilitating access to voluntary work and community services, as well as providing other practical and emotional support. The Case Manager always works in partnership with the client and their family (where applicable) as well as the referrer and other professionals involved, usually acting as co-ordinator and first point of contact.
Rehabilitation is an active process by which those individuals with disabilities realise their optimal physical, mental and social potential. It is often essential to enable clients to regain skills for everyday life after a severe brain injury, and therefore an integral part of case management provision. We generally follow the neuro-functional approach to rehabilitation.
In the case of community based rehabilitation packages we liaise with all involved including the client, their family and therapy professionals to establish and co-ordinate timely and cost effective rehabilitation programmes. Rehabilitation plans are designed to be specific to the clients' needs. Rehabilitation professionals (including psychologists, speech and language therapists, physiotherapists, occupational therapists, vocational specialists, as well complimentary services such as personal trainers, equine assisted therapists, etc. as appropriate) are responsible for the therapy programme and, in liaison with the Case Manager, facilitate the education of family members and the training of Support Workers to maximise the client's potential for progress. These programmes are reviewed regularly to evaluate their effectiveness and dynamically changed according to the client's needs and family circumstances.
Alternatively we can co-ordinate admissions to inpatient rehabilitation units and work closely alongside them, eventually co-ordinating discharge back into the community.
Many clients benefit from the input of Support Workers (also sometimes known as Rehabilitation Assistants, Carers or Personal Assistants, depending on the client's preference), in which case the Case Manager works closely with the client to identify their preferences and needs and then sets about establishing the appropriate level and type of support. This may involve commissioning suitable Support Workers through specialist agencies, or by managing the recruitment and direct employment of staff on the client's behalf. In both cases the client and family are involved in setting criteria, interviewing and choosing the right people to work with them. Where support staff are directly employed by the client, the case manager is supported by the Human Resources team to ensure relevant employment checks are carried out prior to the support worker commencing work with the client, and to ensure best practice within employment law to manage any employment issues, including leave entitlement, disciplinary measures, etc. The Case Manager monitors the input of Support Workers through client feedback, daily logs and timesheets; ensures appropriate induction training and written guidance is provided as well as any other relevant training throughout the year; and carries out regular supervision and annual appraisals.