Practice Issue:

You receive a new client handed over from another case management company. The client sustained a brain injury and is wheelchair dependent. As a result of the brain injury he has dysarthria, but remains fairly articulate. Despite being able to express himself well he sustained cognitive impairments and gives a better account of his abilities than is the case in practice. He also has challenging behaviour, which is particularly triggered when his view or decisions are challenged, there is a lot of change or uncertainty, or if actions set out do not go to plan. He has a financial deputy and you have concerns regarding the extent of his capacity to make decisions about his care and rehabilitation.  He is being supported by a domestic care agency and is working with an MDT on a list of 13 goals.

How do you make a coherent plan and address the goals which the client is now adhered to?


Case Management Actions:

  • Get to know the client, spend time with them and discuss how they want things to be and how they wish to be spending their time.
  • Understand the client’s pre-injury situation.
  • Ensure you have an accurate picture of the client’s sensory, physical, communication and psychological abilities.
  • Formulate the nature of the client’s difficulties and as far as you are able inform yourself about their level of capacity in relation to specific decisions you are considering.
  • Consider seeking a capacity assessment if you are going to be asking the client specific questions regarding his care or rehabilitation.
  • Arrange an MDT to review what inputs are being provided, therapists’ opinions on the client’s functional level and therapists’ goals and plan for input.
  • Under discussion with the client agree which goals are their priority and try to reduce to a manageable active list of approximately 5. Review with MDT to see if other goals are a priority for client safety.
  • Review support being provided as part of your plan and assess the competency level of support workers involved.
  • Document the agreed goals, the client’s wishes and aspirations, the MDT notes and the case management plan for a comprehensive, interdisciplinary way forward.

Skills used from competency 2:

2a) Assessment and goal setting

2b) Planning


Positive indicators demonstrated:

Needs are correctly addressed

A comprehensive rehabilitation plan is formulated with a clear way forward

Relevant goals are set at the right time

Progress can be made on goals because it is meaningful to client

Case management plan is rehabilitative in practice

Case management is flexible

Goals prioritised in a way that maintains client safety


Bear traps avoided:                 A lack of a clear way forward due to too many goals

Trying to implement a rehabilitation plan without the right team and without the client being correctly supported

Case management being reactive

Using the same plan for different clients; a “one plan fits all”

Losing engagement due to client being overwhelmed

Not recognising the true needs by working outside one’s own scope of practice

Client did not make incapacious decisions


Competencies:           Communication


Duty of Care

Personal Attributes


Referencing:    Mental Capacity Act 2005

Evidence-based practice on goal setting


Practice reflections:

Although there were a number of issues which required to be addressed here, they couldn’t all be done at once. The client struggles with change and implementing a wholesale switch of his care and goals was not possible if we were going to minimise the impact on the client.  It was a matter of prioritising the client’s needs, safety and working such that the client’s capabilities, both mentally and emotionally were not exceeded.

Due to his challenging behaviour the client was making decisions about his care which he did not have the capacity to make. However, he was enabled to do this by the previous team to avoid eliciting the challenging behaviour. To work in a client-centred way, it was important to support him to be involved as much as possible in any decision, but his safety is also paramount.

The number of goals on this case meant that progress wasn’t being made.