About Social Return Case Management

Mr F experienced a prolonged period in hospital and a difficult acute phase recovery after sustaining an injury at work. He was recently discharged from hospital when our Case Manager met him. He felt low in mood and was finding it difficult to adjust to his new circumstances. He dearly wanted to return to being a father and husband, and to be able to return to driving following a severe brain injury.

Mr F was a young man of working age and was enjoying the start of family life with his wife and 2 year old son. He viewed his main responsibilities as being husband and father, and also providing a valuable contribution both practically and financially into the family home. He had spent a lot of time renovating the current family home and was part way through when the injury occurred.

Mr F and his wife had a close circle of friends and work colleagues, and enjoyed an active social and family life – both he and his wife worked full time. Mr F worked on a construction site, and the injury occurred when a pipe fell on his head at work causing a severe ABI.

A summary of his injuries include:

• Depressed skull fracture
• Subdural haematoma
• Subarachnoid haemorrhage
• Brain contusion

When our case manager met him at his home for the first time, it was evident that there were may overlaying factors to his presentation, including the impact of his injury, difficult experiences in hospital, low mood, and new experiences of feeling incapacitated and more vulnerable.

Mr F was discharged home to the care of his wife who was trying to come to terms with the injuries her husband had sustained, as well as hold down a full time job and care for their young son. The date of discharge was brought forward earlier than planned due to the onset of the COVID-19 pandemic with Mr F’s consent. As a result, no pre-discharge home assessments or planning was able to occur, apart from sending him a commode, perching stool and later on a manual wheelchair.

On the first home visit, the Case Manager arrived to find Mr F in a single bed in his sitting room, with daytime TV for company. He was in pyjamas, and was unable to independently move around his own home. Our Case Manager was able to spend time with him, understanding the difficulties he was facing and what he considered the priorities to be in order to improve his situation.

As part of the overall assessment, the Case Manager prioritised risk management and also identified emerging evidence of cognitive impairment and psychological needs. Mr F’s goals, which were to:

• Regain his independence
• Negotiate the stairs in his home
• Be able to put his son to bed
• Sleep in the marital bed with his wife
• Would like to drive again
• Would like to walk round the park with his son
• Go to the shops and buy food, prepare evening meal
• To be able to do the family laundry
• To have ‘less pain in my arm’

The Case Manager used his goals in several ways:

1. To regularly review with him if they were changing or developing and if the rehab programme was aligned with his goals
2. Develop outcome measures with the MDT to quantify progress made (using SMART, GAS and other modalities)
3. To develop a case management action plan which was reviewed monthly and maintained the momentum towards progress
4. To align the MDT clinical goals with Mr F’s personal ones

Mr F was having some NHS community based therapy via OT and PT. The Case Manager enlisted some specialist independent therapists including OT, PT and Neuro Psychology to assess, and then provide treatment, to top up state provision.

It was important that the MDT, the client and the Case Manager were all working towards the same trajectory and use of the client's goals ensured that clear and comprehensive plans were agreed with Mr F and the team collegiately.

To ensure safety and provide foundations for Mr F achieving his goals some of the first important steps implemented by the Case Manager included:

• Referral to fire service for home safety check
• Installation of a high tech door entry system
• Liaison with council for a dropped kerb
• Referral to local spasticity specialist service
• Referral to psychology and neuro-psychiatry
• Referral to Sex and Relationships Clinic
• Assistance with benefits claims
• Implemented care package
• Assistance with coordinating patient transport
• Referral to a driving assessment specialist centre

Mr F was doing extremely well in progressing his goals. He was very dynamic in his attitude to recovery and in working with his team – and as a result these are the goals he achieved:

• Able to negotiate the stairs in his home and out of the front door, and then later walking around the park with his son
• Improved mood
• Cognitive strategies implemented
• Able to put his son to bed
• Sleep in the marital bed with his wife because pain was managed
• Go to the shops and buy food, and prepare family evening meal and do the family laundry
• And then driving - on the road to regaining independence!

Mr F has made remarkable progress with his team as a result of having a clear assessment of needs which takes into account all factors and generated defined client goals. The comprehensive rehabilitation plan included identification of specialist resources which assisted the client in achieving his goals, facilitated by a specialist MDT. The Case Manager engaged with the team to ensure regular review and monitoring of progress, ensuring clear team objectives and collegiate approach.

Mr T sustained a spinal cord injury in a road traffic accident, and initiated a personal injury claim with the support of his solicitor. A Case Manager was introduced to assist with Mr T’s recovery. After a period of time working with his Case Manager, Mr T instructed his Solicitor of his wish to change provider. A ‘Beauty Parade’ was arranged and he then met and chose to work with a Case Manager from Social Return.

An assessment, including history of the accident and update on current situation, and a hand over of Case Management work undertaken to date was collected during a home visit by our Case Manager and the main priorities identified at that time were to:

• Source a suitable vehicle to accommodate the client, his family, and his wheelchair.
• Source a suitable profiling and pressure relieving double bed and mattress arrangement for client
• Arrange for purchase of a suitable armchair to reduce time spent in bed and offer alternative pressure relieving postures
• Discuss the spectrum of available pain management services with a Consultant in Rehabilitation and to co-produce a plan for comprehensive pain management which included, and went beyond, pharmacological interventions.
• Introduce a specialist Dietician for weight management, nutrition and pressure care/skin maintenance
• Identify Private Urology support for long term catheter management and UTI infection prevention and support to supplement NHS provision

The outcome of the assessment, and associated recommendations were discussed with Mr T. The report was shared with his litigation team, identifying short and longer term support needs and also some ‘quick wins’ that could have a big impact on current life issues. The report set the scene for further funding to be secured, to implement clinical recommendations and address the rehabilitation needs Mr T presented with.

The Case Manager established a positive working relationship that ‘fitted’ with the preferred approach of the client and family, ensuring an effective and an unobtrusive presence, and promoting the client's ownership of his own recovery. She endeavoured to support and role model with a view that Case Management would eventually become Self Management over time.

Mr T identified his goals and worked with his MDT to progress them. Multi Disciplinary Team meetings were held to establish an effective communication pathway with the client, Case Manager and the MDT. Timely provision of update reports was essential to progress the case both for the client but also in assisting the litigation teams with possible ongoing costs of rehabilitation and services that would require funding.

The Case Manager was able to support Mr T through the challenges he and his family faced while he developed strategies to maximise independence as a wheelchair user. Both his recovery, and his legal case progressed to the point where a Joint Settlement Meeting was arranged by the litigation teams. Although Mr T was pleased that there might be some conclusion to the litigation, signalling the beginning of a new chapter for him and his family, he was anxious at the prospect of being involved in what he perceived as being a formal and intimidating process. His Case Manager was able to make arrangements for him and his wife to attend, and offered practical and emotional support so that he could focus on the matters in hand with his legal representatives on the day.

Mr T was positive about the settlement meeting process and commented that he felt involved and really valued the negotiation skills of his Barrister. A settlement agreement was made and his case concluded, allowing him to move on with his life. He continued to work with his Case Manager to put in place some further foundations for him and his family, including finding a suitable property for adaptation and engaging the services of an architect, and Mr T then went on to oversee the adaptation of an accessible property for him to live in with his wife and children. Over time his need for support reduced and he continues to manage his life without the day to day support of his Case Manager, instead troubleshooting on occasion, and managing his own health needs with the toolkit of resources and knowledge he has gained over the time he worked with his Case Manager and MDT.

Stacey is 12 years old and lives with her parents and two siblings. She sustained a brain injury in a car accident 7 years ago and despite having an experienced Case Manager in place from another company, there was not sufficient funds available for the Case Manager to progress with any meaningful interventions. The family were exhausted as difficulties were escalating around behaviour management and impacts on the family, and all of this was affecting the relationship between Stacey’s parents and her Case Manager. We received a call from Stacey’s Deputy enquiring whether we could help her and her family in a time of crisis.

Our Case Manager was able to liaise with the Deputy and previous Case Manager, and meet with Stacey and her family in a property they were renting, as their original family home was not suitable for her to live in. She heard about how Stacey had been out of school for two years and that the family felt unsupported by school and the local authority. They could see no way back to getting Stacey into education and Stacey was herself frustrated at seeing her siblings going to school, and being with their friends when she could not. This manifested in physical and verbal behaviours towards her siblings and was making family life unpleasant and unmanageable.

With the ability to evidence the difficulties the family were experiencing, and provision of in depth analysis and recommendations, funds were secured to address the escalating situation and prevent the possibility that Stacey might not be able to be cared for by her parents, and may need to enter the care system. The Case Manger brokered relationships with school, parents and the EHCP lead to promote communication and collaboration towards achieving Stacey's wish to return to a school learning environment with her peers.

The school and Local Authority were engaged to identify specialist educational support that Stacey required and a selection of schools which the family might consider. As the school had not seen Stacey in person for such a long period of time the Education and Health Care Plan (EHCP) was outdated and did not reflect her needs. The Case Manager was able to provide a clear rationale for home-schooling with a Private Tutor in order to collect information to inform the EHCP as well as provide a bespoke transition towards re-entering education.

Support for Stacey’s siblings was instigated in order to help them understand and manage the changes that Stacey was experiencing and the impacts this was having on their relationship with her. An Occupational Therapist and Behaviour Management Specialist therapist was engaged to put in place behavioural management techniques to support the success of the tutoring sessions. Stacey’s week was set up so that she had time allocated for therapies including hydrotherapy, physiotherapy and horse riding as well as time for rest, family time and play, all carefully balanced around her tutoring.

Stacey’s EHCP was produced, informed by her parents and the team around her which led to starting the new school year in a suitable school that could meet her needs. The school was able to engage Stacey in lessons, provide a dedicated break out area when things became overwhelming for her, and keep her and the children in her class safe from the behaviours which had previously prevented her from being in the classroom environment.

Case Management planning for the next steps is underway: Now that Stacey has successfully returned to full time education, her parents can consider finding their new permanent home which will have accommodation for Stacey’s care team. The date for the end of the tenancy agreement on their rented property is rapidly approaching and the Case Manager is providing assistance to find a new and more permanent solution, to minimise upheaval for the family by avoiding several house moves in the future.

They are also embarking on recruitment of the support team, which will enhance Stacey’s life and reduce the pressure on the family unit. Stacey is being supported by her Case Manager to be involved in the recruitment of her care staff in an age appropriate way, and is looking forward to making plans for new activities which she would like them to help her explore. She will need one to one support with these activities in a managed environment and her support staff will need to employ skills and techniques supported by the therapy team to ensure that Stacey is able to enjoy greater quality of life and friendships within her peer group.

With the support of our Case Manager, Stacey is back in full time education, Stacey’s parents are now in a much better place, and their energy can be directed towards supporting their daughter's recovery and 'being there' for their other two children.