About Circle Case Management

Michelle began working with client L in 2018, who sustained a traumatic brain injury in 2014 at the age of 14 years old. Michelle’s initial assessment highlighted his cognitive difficulties within attention, working memory and executive skills, as well as his low mood and PTSD. Joint goal setting with client L outlined his wish to move from his family home to his own accommodation, and to return to college to complete an Art and Design Course. Client L exhibited little structure and routine during the day, a poor sleep routine and poor initiation to his personal activities of daily living. It was apparent that little therapy input had been received to date, and the need to establish interdisciplinary team working was identified. Assessment planning commenced, and Psychology and OT input established client L’s current abilities and formulated treatment plans to administer in the pre-independent living trial. A support team was introduced to engage Michelle’s client in leisure activities and support him with attendance at a weekly creative writing course, which was organised and managed by Michelle. Michelle coordinated the therapy and support input and sought regular feedback to ensure that expectations were managed well. During this time, client L remained keen to move and Michelle ensured that his insight was developed through regular multidisciplinary team meetings and liaison with the client. Michelle’s role included the completion of thorough risk assessment and management plans, which were shared with his support and therapy teams, as well as updating litigation parties so that funds could be sought in a timely manner. This was also key to ensuring that the client’s expectations were met. Michelle also supported client L with his college application and ensured that he received assistance with preparation for his interview as well as support on the day of his interview. Michelle’s support was extremely beneficial to the client, giving him confidence, a higher level of well-being and better coping skills, whilst reducing stress and anxiety levels.

Michelle planned and prioritised well to seek suitable living accommodation for client L. Since the property market is highly competitive, Michelle managed her workload and clinical responsibilities well to view appropriate properties when they become available. Client L’s impulsivity was evident at this time as he was desperate to move out of his family home, so Michelle’s communication skills were used in an effective way to reason through why some properties would not meet his needs. Client L respected Michelle’s judgement, and this was indicative of her strong therapeutic relationship with him and the trust he had placed in Michelle. A suitable student flat was found, and Michelle’s work then began to assist the planning of his move.

With 1 week to go prior to his move date, we received the unfortunate news that his care agency had decided to no longer support client L due to their concerns that they were not skilled enough to manage his needs. At this time, Michelle exhibited a calm and measured response to manage the client’s anxieties, as well as a proactive approach to sourcing support from an alternative provider. Michelle researched agencies that would be able to provide the services that the client would need. A suitable provider was found after a successful meeting with their team leader which allowed for the discussion of the client’s need to ensure that they were adequately trained in brain injury. The care agency were able to demonstrate flexibility in their provision and members of the support team quickly established a good rapport with the client which proved important in the coming weeks where client L’s motivation and mood would deteriorate, and the support workers were well placed to challenge his performance at home.

The Covid-19 pandemic arrived at a time when client L was only 4 weeks into his independent living trial. Michelle established the appropriate risk assessment and management plan for his support team, in conjunction with the team leader. Since Michelle had planned a high level of support during this transitional move and could no longer carry out face-to-face work, she moved to virtual meetings with client L and his therapy team which proved to be successful in monitoring his needs. Client L was originally keen to attend the gym so creative thinking allowed for the exploration of virtual personal training sessions as well as yoga tutorials. Michelle regularly “thinks outside of the box” for her clients, so that they may access the services and therapies they would like for their rehabilitation. Michelle works extremely hard to build long lasting, honest, and open relationships with her clients, which installs a level of trust so that clients feel that they can make these requests and Michelle will manage their expectations and evaluate the need for the service requested and the impact it could present for their rehabilitation.

Since client L had been successful in his college application, Michelle began to explore his love for art and design with equipment and activities that he could undertake within his home environment whilst lockdown measures were in place. It was important for client L to maintain a routine which he had worked well to establish in order to maintain his mood and well-being. This was very important as the client became more engaged with therapy and SMART goals.

Client L settled his case in December 2020 and Michelle has continued to support him with the next chapter of his student life. Client L has been successful in his university application, and he will be moving to a new geographical area to undertake a Fashion degree. It has been wonderful to support him in his transition to a confident young man, homeowner, and university student, and Michelle reflects on her own learning during a challenging time with much admiration.

Maria is a Specialist OT, Case Manager and Vocational Rehabilitation Expert, with over 20 years experience. She is highly accomplished in leading negotiations with employers to secure a return to the workplace or new career path. With comprehensive clinical experience, she manages a varied caseload, working with clients who have suffered life-changing injuries and illnesses and has previously worked with injured military personnel and the Royal Household. Maria has recruited and led significant therapy and rehabilitation teams in hospital, community, and Ministry of Defence settings, setting standards, training, and motivating care teams to deliver outstanding care and rehabilitation.

Maria is tireless in her pursuit of removing barriers and obstacles to enable her clients to return to education, employment, and meaningful activity through her work. Maria is currently working alongside T – who was involved in a road traffic collision in 2014. Suffering a Traumatic Brain Injury. He sustained multiple injuries including fractures and required a significant period of hospitalisation and rehabilitation. He initially required a tracheostomy and PEG and developed post traumatic communicating hydrocephalus in 2014 requiring shunt insertion.

Vocational Case Management was recommended in order to help T to continue either with: Antiques as a hobby which is better managed, or start a profitable self-employed business of buying and selling antiques, or to identify any alternate occupation/interest that could be pursued. T had extensive antiques stock. He would constantly want to purchase items but was making few sales. The stock were an added falls and safety risk to him and his support team. In addition, he was purchasing stock with added costs therefore at financial risk of decreasing his Trust fund budget. Resuming part time work with support would not only provide him with a sense of purpose, income but reduce falls and financial risk. Prior to VCM input several attempts had been made by other Case Managers to engage him in the vocational process but without success. It was vital that the VCM understood his personality and what motivated him regarding his antiques business to ensure he would engage and achieve his goals of resuming part time work. Fatigue varies daily which impacts on his physical and cognitive function plus mood. Issues with short term memory, difficulty information processing, organisational skills and executive function. T’s goals within six months were to resume working part time, self-employed or as an antiques dealer and being in profit. In order to achieve this goal, to gain help from Case Manager, Vocational Case Manager, Support Worker and Psychologist to enable him to make a profit and income of £5,000.00 within six months from stock held within the antique centre(s).

As a result of lockdown and reduced subsequent motivation from the client, Maria chose to “think outside the box”. Maria created a video explaining the benefits of him having a second antique sales centre in another emerging antiques location after liaising with three antiques centres. The video message focused on Maria’s knowledge of the client and the reasons why he disliked online sales and what motivated him for selling.

Maria met with client and support worker to discuss the video and vocational goals. As a result of the video and meeting with Maria, T agreed to add another location for antique sales. Maria enlisted added video assistance (as he had engaged and responded positively to this approach) with Circle Marketing Manager to compile a second vocational video for the benefits of online antiques sales. All previous attempts to entice him to complete online antiques sales had failed.

The 12-minute video included a “Dragons Den” pitch style to engage the client motivation of making a profit. It used simple language, recorded Maria’s explanation, photos or visuals describing benefits of online sales, case studies from other antiques sellers who had profited from online sales, statistics of the increase and trends within antiques during lockdown. Maria discussed with Client that he has many trending items in stock. He has personality, experience and a passionate interest that would engage younger customers to purchase from his online sales.

As a direct result of watching the video and discussing it with Maria, Client agreed to allow his support team to assist him set up a Facebook Marketplace site for online antiques sales. New updated online and offline sales targets and vocational goals have been agreed. Client completes restoration, photographing and listing with support of 5-10 items a month on his online sales page. He has support to keep a more regular and updated stock list of what an item cost, where it may sell and any profit margins.

Client has eloquently explained to Maria why he buys each item and who might be interested in purchasing it. With support the aim is for him to add these “item descriptor videos” to his online sales page. Maria has also suggested he could guest speak about buying antiques at various events or groups such as U3A. Maria is delighted that the client has engaged in this manner given that post accident Client could only speak a few words and could not recall more than 1-3 words. Last month he had identified 5 “quick wins” to sell on his Facebook page and aims to continue to do so each fortnight. His Support worker will help him upload the images and details onto his FB site.

Maria aims to discuss other ways to generate income therefore to provide support for him to sell through:

• 3 physical sites/locations/auction houses
• Facebook page -now set up
• 2-3 online portals such as through Instagram or other identified

Due to his accepting and understanding of the process Client is on target to have multiple methods of sales to achieve (or exceed) his initial profit goal of £5,000 within six months and return to part time work self-employed. Due to the success of the vocational video, language, style and images used by Maria, another video was made helping his Case Manager explain changes about his care to help him retain longer term funds. Client accepted the changes more easily as a result. Prior to the video method he always demonstrated negative or demotivated mood with any changes. He understands about his finances which is another added motivation for him making a profit from the antiques sales. Throughout the process Maria has attended or had input into Multi- Disciplinary Meetings attended by client, support worker, Case Manager and Psychologist.

To ensure that client and MDT concerns/issues were addressed Maria prepared an update of vocational goals and actions required by all supporting. Regular telephone or face to face meetings were held with the client and support worker or Marketing Manager to ensure vocational case management goals were met. Vocational updates were included within the Case Manager progress reports detailing vocational progress of SMART Goals and future plans.

Maria has since secured free social media training for Client to continue his success; he is visiting sites more regularly with his support team, to monitor and replenish stock as his sales have dramatically increased at antiques centres.

Client C was 7 years old when Caroline became his Case Manager. All his family members were involved in a RTC in August 2018 all suffering various injuries. However, Client C who was seated behind the driver received the most severe injuries including a severe brain injury, multiple facial fractures and the loss of an eye. Fatigue and pain are also major components of his injuries and impact on his everyday life.

Client C is mobile, although he has some residual weakness, has severe cognitive problems and epilepsy. He is impulsive in his behaviours, is not able to sleep without medication and needs to be supervised with all his personal care. He is also not able to self-occupy and doesn’t like to be left alone in a room.

Client C returned to school a year after the accident on a part time basis. He has an EHCP and the teachers and LSA have received training on Fatigue management and his brain injury. He was attending school part time to allow for a rest day and also, he was still having lots of hospital appointments which took place on his ‘rest’ day along with 1:1 swimming lessons as he couldn’t swim with his peers.

When Caroline took over the case as Case Manager client C had private Occupational Therapy and Physiotherapy. The Local Authority had no therapists qualified to work with a child with complex Neurological injuries at the time. Client C had no psychological support as again no-one had been identified with the skills to work with a child with PTSD. He also had no Speech and Language Therapy.

Dad had returned to working in London, Mum had not been able to return to work due to her health issues and the need to co-ordinate all the medical appointments, etc that client C required. His sisters had returned to school.

The family lived in a semi-detached house with limited space for therapies / support or space for client C to rest when fatigued. It also did not have a downstairs toilet which client C found difficult due to his need to be supported to use the toilet. Caroline identified the following: -

• The need to adapt the current Property or adapt a purchased property
• Safe play garden
• Support Worker recruitment
• SALT
• Psychology
• Local Authority O.T and Physiotherapy if possible
• Orthoptist and low vision specialist
• Leisure activities that he could participate in with his peers
• Alternative therapies eg; Yoga, Rhythmic Movement Therapy

Covid has been challenging for the family. Client C was due to have major reconstructive surgery to his face which was cancelled 5 times. The family went into isolation to ensure that client C was well enough to have his surgery, his sister has been home schooled as well and Dad has been working from home. Mum’s health has been poor resulting in her having to be on bed rest most of the time increasing the demands on Dad.

Caroline has increased the support she gives to the client’s family virtually with video calls and on the telephone, especially as their responsibilities and routines have changed drastically. The emotional support given has been invaluable to ensure there has not been a detrimental effect that would affect the client’s rehabilitation journey.

Therapies have continued virtually including, Physio, OT, SALT and Music Therapy which have all been very successful. Client C has been home schooled using a visualiser and his Granny who is a retired SEN Teacher has been teaching him virtually. With this specialised, bespoke teaching client C is now at the same level as his peers in English and Maths. He has been attending the Local Authority science lessons with a small group of children which he has enjoyed. Caroline had researched and put in place all of the above therapies and services – ensuring that they were the right fit for the client.

Client C’s support worker, who was recruited just before the pandemic hit, has continued to support him virtually playing games and working on turn taking, not always having to be in charge, allowing others to win and choose the games and on his social skills. She has introduced other children to the games which client C has really enjoyed. Monitoring forms were put in place by Caroline to monitor client C’s responses, mood, fatigue, etc to ensure that the support was meeting his needs. The Music Therapist also worked with the support worker on monitoring emotional regulation.

A large part of Caroline’s role has been supporting client C’s parents, but also attending site meetings for a house that was identified as suitable for adaptation in November 2019 with the works starting in January 2020. As the parents have been unable to attend the site meetings, Caroline has attended on their behalf, video calling them during the meetings so that their voice can be heard and also writing up notes in layman’s language with the actions that they needed to complete and a timeframe.

Client C’s medical care has also been transferred to another hospital during Covid to enable his clinical care to be co-ordinated better and to reduce the amount of hospitals involved. This again has been very challenging with Caroline needing to co-ordinate this for the family, attending appointments if required to do so.

Client C successfully had his operation in May 2021 and is making a very good recovery. It is hoped that he may be recovered well enough to attend school at the end of term.

It is hoped the family will move into their new home by September 2021 with a fully adapted safe garden, researched and co-ordinated by Caroline.

Client C also identified that he would like an assistance dog. Due to his facial injuries he has had some ‘horrible’ comments from other children when he has been able to go to the local park to play. He has lost a lot of confidence due to this and lockdown. Caroline has started the assistance dog process which is very exciting for him. The dog will be trained to detect seizures which have increased recently due to him growing and the beginning of puberty.

Client F was involved in a road traffic collision in August 2017 whilst riding his moped back from his summer job as a yacht hand. He was airlifted to hospital from the island to the mainland.

He sustained a right open distal femoral fracture initially managed by external fixation, open reduction and internal fixation. His dislocated his left shoulder was relocated in theatre and Fractured toes right foot were treated conservatively. He underwent an anterolateral thigh flap from left leg to cover right knee.

Client F initially received surgery and therapy from NHS rehabilitation service. He had a Case Management Immediate Needs Assessment completed in November 2017. The initial Case Manager had arranged a private Orthopaedic consultation which revealed non- union of the femur and the possibility of amputation if the non -union did not improve.

The Case was transferred to Di Magrane at Circle Case Management in April 2018 as the client and family were dissatisfied with the lack of progress made. The client was in significant pain, he had limited functional use of his right leg and was dependent on his parents for assistance with all activities of daily living. Client F felt as if his life was on hold as his friends were enjoying their first year at university. Client F was unable to leave the house due to being unable to flex his knee sufficiently to get in the family car. There was an extremely high level of stress and anxiety within the family.

The client’s priority was to address his clinical needs and to save his leg. Di Magrane organised a 2nd opinion with a Private Orthopaedic Lower limb consultant with a specialism in knees and lower limb reconstruction. Di attended all Orthopaedic appointments with her client and his mother and completed a record of the discussion of the clinic appointment to assist with the instructing parties understanding. Also, Client F has dyslexia and is very easily overloaded with information, tending to switch off. Di’s attendance at the appointments has been extremely beneficial in being able to effectively co-ordinate Client F’s rehabilitation. The informal time spent in the waiting room has been excellent for building a rapport, clarifying concerns and understanding what is important for her client.

Di arranged for a Pain management consultation prior to the initial surgery and several subsequent reviews. This has been highly effective and managed any possible risk of dependency on pain medication.

The client’s leg was very unstable due to complete ligament damage. Di arranged an Orthotics Consultation where the client was provided with a bespoke knee brace and bilateral insoles. Di arranged for regular reviews following surgery and the provision of a lighter weight knee brace as the clients’ mobility and leg strength improved.

The Orthopaedic surgery has been complex, to date Client F has undergone three rounds of corrective surgery and one further one is due. Following the first major surgery Di arranged for a further second opinion from a professor of Lower limb reconstruction. His report indicated a different approach to addressing the misalignment. The subsequent surgery using this information greatly improved alignment to allow for bone union to occur. Prior to each surgery preparation for rehabilitation was co-ordinated through a Multi- Disciplinary Meeting attended by the client, his family, support worker, Occupational, Physiotherapist and Psychologist. In order to ensure that all concerns/issues were address Di prepared an agenda before all meetings. Prior to the MDT meeting therapist were requested by the Case Manager to prepare progress reports detailing progress of SMART Goals and future plans. The frequency and intensity of visits were discussed and the costs of these agreed by the joint instructing parties.

Di directly employed a support worker to assist with activity of daily living and the implementation of the Physiotherapist and Occupational Therapist programmes. The OT co-ordinated Client F equipment needs adjusting to his changing abilities.

Client F was keen to go to university to study media studies. Di was able to arrange the purchase of a camera and laptop which enabled him to develop his interest and motivated him to mobilise more to be able to take better photographs. Client F as successful at gaining a place a university although became very apprehensive as the time drew closer. Di arranged for him to have psychological support to talk through his concerns and process the trauma of his injuries.

Initially Client F was in hall of residence in a designated disabled access room on campus. For his 2nd year Di sourced a ground floor flat and furniture and he was able to share with his sister who supports him with domestic task as specified in his care plan. There was a gym within the complex which he was able to use with his physio and support worker. He is due to graduate Summer 2021.

Di arranged handover reports from one treating Physiotherapist to another and has continued to monitor ongoing provision. Client F has gradually gained more understanding of his injury and the need for a lifestyle approach to rehabilitation. He has adapted his own bike for use on a turbo stand, he does some yoga and goes for walks.

Di initially arranged for the family to have a hire care and taxi account. After the latest round of surgery, she was able to arrange for a vehicle assessment for Client F. He is now driving his own adapted VW Golf (on hire). This has been liberating for him. It also meant that he was able to safely travel during the pandemic. Prior to his injury Client F was a keen skier. Over the last 2 years he has developed his sit ski skills and now drives himself to volunteer as a sit ski instructor.

Di has been able to share clear treatment plans and goals with the two instructing parties through regular case conferences. The insurer has invested heavily in the rehabilitation programme due to the progress made.

Client F has continued with weekly Physiotherapy sessions and exercise at home in spite of Covid 19 lockdowns. Di followed the covid protocol guidelines and face to face continued in line with regulations and in a safe manner.

Di ensured consultant meetings continued via zoom, because she has such a good relationship with the medical staff Di was invited to join the meeting. The virtual meeting proved to be successful and actually worked better for the client as the consultant was able to share images of X-rays on the screen, giving the client a visual as well as conversation to understand the images and have Di available to ask any forgotten questions and to ensure the client understood everything discussed in the meeting.

Further Ortho-plastic surgery is planned for early Summer 2021 with physical rehabilitation planned for Summer 2021. Client F and Di have discussed future life plans and what creative vocations would be suitable. If Client F is successful in gaining a place for his MA in film, Di will assist him to relocate to another city, find a level access property and physiotherapist. He hopes to be living with his girlfriend.