Transcript CMS

Dr Bill McKinlay
Neuropsychologist, Case Management Services Ltd
Associate Editor, Brain Injury
[email protected]
www.caseman.co.uk
Long term problems after TBI
Physical/sensory/epilepsy
Cognitive
Esp. Memory; attention; executive function
Emotional-behavioural
Esp. Reduced ability to regulate mood/temper,
apathy/tiredness, altered social behaviour
Most frequently reported problems after SHI - as
observed by relatives (% reporting)
Slowness
Tiredness
Irritability
Poor memory
Impatience
Tension/anxiety
Bad temper
Personality change
3m
86
82
63
73
60
57
48
49
6m
69
69
69
59
64
66
56
58
12m
67
69
71
69
71
58
67
60
McKinlay, 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….
 Aggression
 Poor motivation for leisure activities
 Fatigue
 Obsessiveness
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 centres
 social clubs
 physical activity - swimming/gym
 household tasks, e.g. shopping (basics/planning)
 social activities, e.g. lunch/ pool/pub/gigs/clubs
 home-based hobbies like drawing/painting/crafts
 voluntary work (e.g. teaching people with a disability)
Our Team
 Neuropsychologists
 Psychologists
 Occupational therapists
 Physiotherapists
 Nurses
 Social workers
 Rehab assistants
Agency v other employment methods
Pros
Cons
Consistency
Loyalty
Maintaining cover
difficult
Agency
Resources (bank)
Accountability
Avoid conflict of
interest
Staff variability?
Employment by case
management company
Maintain cover
Conflict of interest
Consistent staffing? Difficulty with bank
Time taken
Direct employment
(client/family employ)
(also acting as nursing agency)
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-setting
Physical/ADL
 Barthel ADL, Nottingham Extended
Cognitive
 MMSE, ACE-R
Social engagement
 Community Integration Questionnaire
Mood state/wellbeing
 HADS
 Life Satisfaction Questionnaire
Setting goals
 Client-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-setting
Goal Grid
Keep financial
record sheets
Review
completed
sheets
Agree target
amount to
save
Achieved
1.6.10
Achieved
1.6.10
Try to agree
on 16.6.10
Achieve
target for 1
week
Achieve
target for 4
weeks
Discuss and
review
Online progress notes
 Kept on server
 Available to relevant team members in office or
remotely
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”
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21, lives alone near family
Injured in childhood, never worked
Hit by a car, head injury with GCS 4/15; PTA>4 weeks
Damage to R temporal lobe
Cognitively distractible, poor planning, memory problems
Physically mobile, but some residual limitations (slower,
pain, can’t carry)
 Main problem is anger management – verbally and
physically aggressive in past
 Has girlfriend (about 18 months) with learning difficulty; no
children
 Has a trust
Case study: “Derek”
 Referred well after settlement – family members struggling
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to cope
When 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 car
SWD risk-assessed – staff no longer to take him by car
This in part led to him refusing service – he had no service
for several weeks – heavily dependent on his mother
Case study: “Derek”
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Issues which were apparent included:
Derek had been given no choice of provider
No structure to his week – he did nothing
Provider said it was his “choice” – his ‘frontal’ problems
meant he found it hard to make a choice
They did not support and encourage him with clear options
They did not prompt/encourage him to participate in
household tasks – so poor diet/takeaways
They did not support him to plan shopping by first reviewing
what was in the cupboard
If 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 appointments
 Aggressive 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”
Now
 He has support 36 hours pw – 6hrs on 6 days – no night cover
 He spends 2 nights pw at girlfriend’s
 More active socially – bingo; pub (modest intake); looking to
resume swimming
 Now shops and cooks – enthusiatically
 Hopes 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 night
Costed at £12/hr = £1344pw = £46592 in 8 months
(not counting “on call”)
Care now = 36 hours per week
Costed at £12/hr = £432pw = £14976 in 8 months
Saving = £31616 in 8 months
Family members as guardians
 Family 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 SWD
2. CM, SW, Psychologist discussed with Derek change of
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provider and his expectations/obligations
CM provided info on various possible providers
Derek chose based on this information – he understood
they knew about head injury
Met with their managers – and with CM planned a service
specification.
Derek and CM interviewed existing staff who might be
suitable
Derek chose staff with support – he was involved
throughout and has “ownership”
Case study: “Derek”
1. CM did brain injury training with the staff
2. Team leader and CM agreed and planned weekly structure
with Derek
3. With prompting and support to choose he now:
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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