Case management

Reconstructing Lives :
A Case Manager's ToolKit 
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Case managers often work with clients whose injuries have brought great complexity to their lives and where on initial assessment, there seems to be a plethora of aspects to capture in the initial report plus a raft of recommendations to put forward to support progress toward agreed goals or objectives. It is not a surprise therefore, for clients and families who may be faced with reading the reports to themselves feel quite overwhelmed by their complexity.

Then comes the point where recommendations and costs are agreed, and the case manager can start working with the client and their family to improve their situation. Sometimes the start point is clear but a lot of the time it can be hard to know where to begin. There is an implicit expectation and need for change and progress to happen quickly across many aspects of the client’s life. For some clients, the reality of being able to start planning to engage in some rehabilitation or to pursue a new work or social avenue does not feel easy. 

It is certainly harder for most to turn their goals into reality  than it is to discuss them in the abstract.  it is not uncommon that the client may themselves find it hard to get motivated to overcome barriers.
The case manager can feel a weight of responsibility to create some difference, to act, to implement… after all, they wrote a report with recommendations – a ‘clinical promise’ of sorts. Their notes and progress reports will of course be scrutinised along the way.
Many case managers began their careers in health or social care settings where there is a limited timeframe to make a difference for each person – patients in an NHS rehabilitation unit or on a ward predictably have to move on so that each service can take new patients and focus what it offers to best effect across a population of patients. Unavoidably, this creates pressure to support as much achievement and progress as is possible in whatever time can be had. This is the way many of us became used to working and the shift in focus when becoming a case manager can feel exciting but very different.
Working as a case manager in the independent sector offers a different opportunity, where what is provided can be shaped around each client and where the timeframe and approach can be tailored to the individual’s needs, aspirations, and abilities.

Alongside the experience, skills, clinical and professional knowledge exemplified in the CVs of case managers it is important to utilise powerful ‘tools of the trade’ including:

Time and pacing – for many and often very individual reasons recognising the value of time, grading, and pacing in the pursuit of positive change is important.

Degree shifts and incremental change – one small shift of the right kind carried forward can result in great change down the line. Very small, stepped changes can be a powerful way to build progress.

Quick wins and low hanging fruit – targeting priority areas which can be quickly and effectively addressed helps
to build momentum.  It also,  importantly creates motivation as well as trust and belief in the case manager and the process of
case management.

Individual and collective thinking - case managers often either form or join the MDT around the client. Apparently, it was Aristotle who coined the phrase “The whole is greater than the sum of the parts”.  Never is this more so than with an active and free-thinking MDT where the case manager can promote and facilitate collaborative thinking, whilst supporting the development of individual ideas and plans and bringing this all together to benefit each client.

Curiosity and inventiveness – an open minded and constant curiosity, coupled with innovative approaches which flex in response to individuality and context are needed in order to provide unique and tailored solutions to enhance a client’s rehabilitation progress. 

That mountain of potential for change, documented in the case management assessment report, does not all have to be conquered immediately. After all, as mountaineers know, making it to basecamp is an achievement in and of itself.
The ascent can be tackled another day, with good strategy and in small stages. Success may be positively impacted by waiting until the time is right, careful pacing, alternative routes, and a creative methodology. A team approach to tackle the journey with an inquisitive, innovative, and hopeful, but realistic outlook that balances the risks helps stack the chips toward a safe and positive result. 

Vicki Gilman
Founder of Social Return Case Management 
and BABICM Advanced Case Manager

While the role of the case manager is to support their client, the involvement and needs of their partner and family can be fundamental to the situation being a success.

Here, Virginia Bowley, case manager with ILS Case Management, discusses how this can be difficult to achieve – but the end result can be hugely beneficial for all parties

Being a case manager, I have often wondered how I would react to having health professionals coming into my life and talking about many aspects of my personal and private life, with the details then being reported to others. 
What would it be like to give up any control over what I did because someone else thought it might benefit me? How would my partner react to time-consuming meetings and frequent contact with the case manager and other health professionals? 
This is what our clients have to go through when they instruct a solicitor to pursue a claim for personal injury. 
On one visit, many years ago, I was told that the couple only faced up to the reality of what had happened when I visited. They otherwise tried to mask the enormity of the change in their lives and lived tandem lifestyles which left the client feeling isolated by his wife and not supported. 

From high-flyer to carer
I worked with a client who sustained a spinal injury and whose wife had a very well-paid senior role. She was used to being in charge of matters and delegating tasks to others. She enjoyed her job and had worked hard to achieve her position. 
When her husband was injured, she wanted to be as involved as possible in his care and support which jeopardised her work prospects. As a result, she reluctantly decided to leave her job. She made this decision with real sadness, and it was a source of deep frustration for her.

I decided to have a meeting with her to talk about what aspects she wanted me to do, and which she wanted to be in control of. I realised, to make this work and to avoid duplication of tasks, that excellent communication between us was of key importance. 
The client was struggling to come to terms with his catastrophic injury and sadly became very depressed, as a result it was difficult for him to engage with anything proposed. His wife was very keen to find something that might capture his attention and help him in his recovery. The difference in their personalities was stark. 
Given that I was my client’s advocate, and that I was not working for the client’s wife, I needed to reflect on what approach I needed take to effectively move things forward. We decided to work on hobbies that the client previously enjoyed, and with the help of an Occupational Therapist, agreed goals were drawn up to help him overcome the barriers he was now facing in doing what he used to enjoy. 
Thankfully, we were able to establish a working relationship where the client’s wife felt supported by me as case manager for the benefit of her husband’s rehabilitation.

Anger needing to be managed
On another case, my client was a father of four children. He was living with extreme pain following a road traffic accident in which he was injured. Despite being safe to be left on his own for short periods, he demanded that his wife stayed with him rather than go to work.
His children were not allowed to have friends in the house, for fear of him becoming angry with them, and he had a low tolerance to auditory stimuli meaning that the TV and any other form of noise had to be kept to a minimum at all times.  
The controlling behaviour had a devastating impact on his wife, who eventually stated that unless he accepted paid care support, she would leave him. The anguish my client’s wife was feeling was clear to see, as she had aspirations to progress her career in the educational field. However, the anger and determination in my client was also evident as he seemingly wanted to keep his wife from having any freedom. 
I had to carefully navigate my way through their seemingly unsurmountable differences in order to get the best result for my client and his family. It took time to resolve, but the wife’s ultimatum stirred my client into action and he did begin to realise that not only would he have lost the life he used to have, but he stood to lose his family as well. 

Breaking through barriers
I have also worked with a client who required 24-hour care. He understood and accepted the need for care, but his partner constantly denigrated the staff and criticised their work. The client enjoyed an active social life often staying out very late which the carers accommodated. 
However, when it came to escorting the client on holiday to a music festival, the client’s partner stated clearly what she wanted to do with the time away which differed from the client’s expectations. This caused tension within the care package as the client wanted to experience the festival environment with his partner, which she did not always want to do. 
I worked closely with the team leader to try and resolve the issues raised by the partner, but there was always a deep sense of resentment from her regarding the cost of the staff, and a sense that she did not value them. I reflected on this and decided to talk to the partner to try and break through the barriers to her having a harmonious working relationship with the care team. 
It was a subject that required re-visiting several times and the care team required much support when they felt undervalued. However, through ongoing conversations
and sensitively raising the issues with my client’s partner, progress was made and tensions between her and the care team gradually lessened. 

Overcoming resentment
Another client I have worked with lived with his girlfriend who had become his full-time carer. She had become deeply resentful of how she was being treated by him and decided she wanted to leave. My client desperately wanted her to stay, but the more he tried to persuade her to do this, the more aggressive he became, which had the effect of pushing her further away. 
My task was to reduce the highly volatile feelings that were developing whilst not aggravating my client who had a quick temper. I could see the desperation in his partner’s demeanour, and could sense the sadness in my client when he realised that
he had shown no respect for his girlfriend and had treated her so poorly. He was so keen for her to reconsider and stay. 
Sensitive and timely discussions had to take place with both my client and his partner to enable them to both feel supported, listened to and to enable a way forward for them both. 

Understanding grief
When I volunteered for Cruse Bereavement Support, I studied how grief can affect us, and through my work as a case manager, I have observed that clients and their partners all appear to go through the different stages of bereavement for many years after the accident or injury has occurred.
In my role, I have always found it beneficial to take time to ‘tune in’ carefully to the dynamics of the relationship between clients and their partners and loved ones whenever I am in contact with them. 
Often, an email from a client’s partner can sound like there may be more they want to say, but they cannot or will not commit their thoughts to writing. In such cases, I will call them to allow them to talk things through more freely, and this gives me an opportunity to gain a clearer understanding and gauge what is troubling them. 
It can also convey the important message that as the case manager, I am eager to have as good an understanding as possible of the depth of feeling that both clients and their partners have. I often explain that if partners can say how they are feeling it can free up the client and others to speak more openly. 

Supporting couples to become stronger
Through my 20 years’ experience of working as a case manager with clients who have partners and loved ones, I have found that it is essential to ease into the relationship respectfully, to actively listen to their concerns without judgement, and to be mindful of the language I use to ensure it is not alien to them.  

As case managers, we may well have a vision of how therapeutic interventions and care and support could help our clients, but they are often managing pain, confusion, discomfort, immobility, loss of freedoms and social isolation which can result in a variety of reactions to case management which always demands careful consideration and an open mind.