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:
- To regularly review with him if they were changing or developing and if the rehab programme was aligned with his goals
- Develop outcome measures with the MDT to quantify progress made (using SMART, GAS and other modalities)
- To develop a case management action plan which was reviewed monthly and maintained the momentum towards progress
- 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.