Principles and Guidelines for Case Management Best Practice
INTRODUCTION
This practice guideline is the outcome of a lengthy period of discussion and debate. We are aware that not everyone will agree with every principle or guideline and that changes in both practice and ideas will occur which will mean that this document will need to evolve and grow, and take on board comments and ideas from the membership and the wider profession. It will remain a living document and should reflect the current best practice of all brain injury case managers across the UK regardless of background and practice environment.
We have not sought to develop a 'standards protocol' as we have no system for accreditation and cannot therefore implement standards, but the publication of this document, which first appeared in May 2004 is however one step further on the road to accreditation and uniform standards.
The text needs some explanation. When we refer to case managers this means case management organisations be they single or multiple practice. The case management plan is equivalent to the service user guide/service user plan and the service user is referred to throughout as the client.
The definition of case management is comprehensive and all encompassing and each element may or may not be relevant to all practitioners. Nevertheless the duties and responsibilities of practioners are wide reaching and onerous so we have tried to produce a blueprint for case management practice, which will make our the roles and reponsibilities easier to define, albeit not necessarily easier to carry out.
The Professional Issues group of BABICM would like to thank all those who contributed to this document, and to you for your continued feedback and interaction.
Jo Clark-Wilson
January 2005
1. Professional Responsibilities of a Brain Injury Case Manager
1.1 Qualification
Case Managers should have a relevant professional qualification and have acquired knowledge and experience of working in the field of brain injury.
1.2 Profession
Case Managers must achieve and maintain membership and registration in a relevant profession and be working towards or continiung advanced membership of BABICM.
1.3 Training
Case Managers must pursue Continuing Professional Development, appropriate to brain injury case management.
Case Managers should have knowledge of developments in clinical issues relating to brain injury and use it as part of their evidence-based practice.
1.4 Interests
Case Managers must be aware of issues relating to the duty of care to the client and their responsibility and accountability to the purchasers of the service and/or providers.
Case Managers must be aware of any potential conflicts of interest and declare these to the relevant authority and/or take advice thereon.
1.5 Insurance
Case Managers must have Professional Indemnity Insurance.
1.6 Referral / Discharge
Case Managers must provide clearly defined information about their service with a statement of terms and conditions, where required.
Case Managers must have a written, dated and signed contract for services.
Case Managers must have a written procedure for safe discharge or the transfer of clients to another service
2. Principles of Brain Injury Case Management Best Practice
2.1 Advocacy
The client, whose cognitive-behavioural status inhibits his or her choice, capacity or independent lifestyle, shall receive specific and appropriate help, including advice, protection and support; and
A client shall be treated with respect and as a valued person,with his/her right to privacy upheld, and shall be given the available support to make informed choices, insofar as is practicable to exercise control over his/her own life.
Case Managers should be able to demonstrate that:
• they act in a way which supports the rights of the individual to lead an independent and fulfilled life, as far as possible, based on self-determination and personal choice;
• they facilitate the client to make decisions in relation to his/her own life by providing information, guidance, assistance and support, where needed;
• they help the client to understand his/her rights and appreciate the need for involvement of others and a system to communicate his/her wishes, as required;
• the client is involved, where possible, in decisions regarding any interventions for rehabilitation and care and that his/her concerns are acknowledged; and
• care and support is provided in accordance with the client's wishes, as far as possible and in the least intrusive manner at all times.
Case Managers should recognise that the right to self-determination can involve risk and should refer to the clients's individual risk assessment
Case Managers should actively promote the empowerment, protection and well being of children and vulnerable adults through the services which they provide.
Case Managers should identify clients who have limited insight or are unable to make their own decisions. The Case Manager should liaise with the relevant professions to determine the client's capacity to make decisions about financial management and psychological and physical safety.
2.2 Protection
Clients, especially children or vulnerable adults, shall be safeguarded in accordance with recognised written policies from physical, financial, material, psychological or sexual abuse, neglect, discriminatory abuse or self-harm, inhuman or degrading treatment, whether through deliberate intent, negligence or ignorance.
Case Managers should be able to:
• recognise the signs and symptoms of vulnerability/abuse and take appropriate action with those statutory services involved in child protection or work with vulnerable adults;
• demonstrate that they have knowledge of the policies and have set a strategy for protecting a potentially vulnerable client, developed in collaboration and through consultation with the client, the family and the relevant agencies;
• use their knowledge and experience of working with brain injured clients to identify and manage risks; and
• balance the requirements of confidentiality, with the consideration that, to protect vulnerable adults and children, it may be necessary to share information with other relevant parties on a strictly 'need-to-know' basis.
2.3 Communication
Communication systems must be effective for the diverse needs of the client, the family and relevant others.
Case Managers should be able to:
• build and maintain a therapeutic and professional rapport with the client, the family and other involved professionals;
• demonstrate that an effective communication system has been established between the case manager, the client, the family, the support workers/carers and all other agencies and interested parties in relation to the rehabilitation and management of the brain injured client;
• provide information and education on brain injury to the client, the family, carers/support workers and relevant others, as appropriate;
• to determine through liaison with other agencies the approach and methods of working, the lines of accountability and funding, and the responsibilities of the case manager applicable to the individual case; and
• demonstrate that an effective records management system is maintained for client and support worker/carer information.
2.4 Co-ordination
The client shall be provided with a co-ordinated package of rehabilitation and care/support, which is relevant to his or her current individual needs
Case Managers should be able to:
• demonstrate that a consistent approach is maintained within each support team by distributing a written document,to support workers and other concerned parties which is specific to the client and which contains implementation guidelines for agreed rehabilitation, care and support goals;
• ensure that the client is provided with information on available resources, eg qualified therapists, carers/support workers, equipment, accommodation, benefits, local facilities and vocational placements;
• co-ordinate and manage the provision of rehabilitation, care, housing, support, equipment etc., as appropriate, to meet the identified needs of the client, and within the financial resources available;
• design, implement and co-ordinate, through liaison with the client and relevant others, a case management plan which has realistic and achievable goals; and
• monitor the client’s wellbeing and health and regularly review the quality of care, services and equipment and their continued suitability to the client's needs.
2.5 Management
The brain injured client's rehabilitation and care package shall be managed effectively using evidence-based practice and in line with National Standards and current legislation.
Case Managers should be able to demonstrate that:
• the health, safety and welfare of clients and support workers, is protected and where appropriate, they have an effective human resources policy for the employment and/or management of the carers/support workers working with the client; and
• that they have a user-friendly and properly documented complaints procedure.
3. The Process of Case Management
3.1 Assessment
The client shall participate in a comprehensive needs and risk assessment appropriate to his or her brain injury
Case Managers should conduct a comprehensive and objective evaluation of the client's current status, environment and functional abilities, including the following:
• the reasons for requiring case management;
• family and social status including identifying the primary care giver;
• physical and psychological abilities;
• spiritual, cultural, financial and vocational factors; and
• the client's expectations, learning capabilities and their potential for independence, community reintegration and work.
Case Managers should be able to identify the need for resources and the costs thereof, ascertain the diagnosis and prognosis, assess past and present rehabilitation and care, identify short and long-term needs and ascertain client goals and provider options.
Case Managers should determine the authorisation and funding for case management services.
Case Managers should be able to assess the risks resulting from the client’s clinical condition and his or her subsequent lifestyle.
3.2 Planning
The client shall be supplied with a well-designed case management plan, which states how the assessed needs can be met and the risks managed.
Case Managers should be able to demonstrate that:
• the case management plan is client focused and takes into account the client's preferences and requests;
• the plan has been developed according to the client's needs, including his or her rehabilitation goals, care and maintenance of health, lifestyle and wellbeing;
• the plan has been devised and developed in conjunction with the client and other interested parties;
• individualised procedures for managing the client's needs and risks in everyday life (especially for those clients who have specific needs or the potential to be aggressive, abusive or cause harm) have been established; and
• there is appropriate and adequate liaison with relevant professionals to develop and agree the rehabilitation plans and the means of monitoring these.
3.3 Implementation
The case management plan shall be be implemented with regard to quality, safety, efficiency and cost-effectiveness. All those involved in supporting the client must be working towards the same realistic and achievable short and long-term rehabilitation goals. The client's care regimes shall be established and maintained, according to assessed need, and within the limits of available funding and the client's health, lifestyle and wellbeing shall be safeguarded, taking into account his or her individual needs. Support workers shall receive training to provide for the client's needs and to mitigate any perceived risks.
Case Managers should be able to demonstrate that:
• they ensure that all those working with the client develop the skills to be able to implement a specific programme, which may include rehabilitation, care and maintenance of health, lifestyle and wellbeing;
• they have used their own clinical assessment findings and liaised with other relevant professionals to establish realistic and achievable rehabilitation goals for the client;
• they co-ordinate the rehabilitation programme, in liaison with the client, their families and support workers and rehabilitation professionals, in the most timely and cost-effective way;
• they develop feedback systems to determine whether the rehabilitation programmes are effective and, if not, to seek potential alternatives;
• they recruit, induct and train carers/support workers and monitor their work to demonstrate that the client's needs and the guidelines of care and rehabilitation are being met;
• there are written care plans and procedures, as required, which highlight the client's health, rehabilitation and care needs, and methods of dealing with these;
• systems are in place to ensure the support workers receive sufficient information and appropriate training in order to provide the client's care;
• they have facilitated opportunities for the client to establish a structured and purposeful lifestyle, taking into account preferences and abilities, and incorporating activities, leisure pursuits and social events, plus occupation and vocation; and
• they comply with the relevant legislation relating to the provision of care to people in their own homes.
3.4 Monitoring
Regular reviews shall be conducted to review progress and/or deterioration, and to update goals and related documentation.
Case Managers should be able to demonstrate that the case management plan remains relevant, realistic and achievable and is understood by the client and by those working with him or her.
Protocol for the referral of an appointment to a Case Manager
The Case Manager’s duty of care is, at all times to the client (the injured party).
The Case Manager has a responsibility for liaison with the client’s family, other professionals and support staff.
The Case Manager should acknowledge any referral within 14 days of receipt.
The Case Manager should determine whether he/she has the necessary information to ascertain the suitability of the referral and the kind of service required and should seek clarity, should this be required.
The Case Manager should establish whether he/she has the relevant knowledge, skills and experience to accept the referral.
The referral to the Case Manager should be from the client and/or representatives on his/her behalf, for instance, a family member, the Deputy/Guardian or someone appointed by the Court.
The Case Manager should provide an initial assessment report, outlining the client’s needs, and providing recommendations and estimated costs for the Case Management service.
All relevant funding agreements should be in place prior to the initiation of the service.
Joint referral from two parties is inadvisable and may lead to conflicts of interest with the client and their representatives. Lines of reporting should be agreed in advance.
The Case Manager should provide written terms and conditions and a contract of service to the client and/or his/her representative. This should include time scales for visiting the client, reports and other feedback, as required.
Any Contract of Service is with the client (and/or his/her representative) and is confidential to between those parties unless the client agrees otherwise.
The Case Manager shall take into consideration any medical, psychological, nursing or therapy advice and apply it to any rehabilitation/care regime, in so far as it relates to the client’s present needs, abilities and social situation and the availability of resources.
The Case Manager should be responsible for providing factual evidence as to the work completed and planned and the underlying rationale for it, should this be required.
Reporting arrangements should be agreed with the client and/or his/her representative.
The Case Manager shall only provide oral reports or disclose written documentation, (for instance, notes and reports) with the client’s (or if they do not have the capacity to give consent, their representative’s) consent.
The Case Manager should be independent of the litigation process.
A financial agreement with any other agency other than the client of the Deputy, (e.g. a secretary, agency or an insurance company) does not constitute an authority for those parties to have access to the confidential records of a client, without the client’s or his/her representative’s prior and written consent.
Termination of case management services must be in writing and allow sufficient time for handover
The Case Manager has a responsibility to arrange an appropriate handover to another case manager or other services if required.
Both the Claimant and Defendant may appoint advisors (sometimes called shadow case managers) who may review the relevant case management documentation with appropriate permission. However, these individuals are not the case manager and may not have access to the client without the agreement of the client and/or his/her representatives.