Practice issue:

Client referred just before they are due to be discharged home following acute brain injury rehabilitation, arising from orthopaedic and head injuries sustained in an RTA.  Initial visit on the ward, with client desperate to be home.  Physically limited- 2 people needed to assist transfers, bathroom/WC upstairs and stairlift being fitted. Wheelchair dependent.  X4 calls per day of domiciliary care organised for personal care and out-patient referral made for physio and OT, with ambulance transport, but journey will be upwards of an hour each way.  Husband works and teen children attend school.

Discharge happens and on the first visit to the client at home it becomes apparent that she spends all day doing nothing; unable to even manage the TV remote, and is entirely dependent on the carer calls.  Clear potential to regain function, and twice weekly outpatient rehab seems inadequate and unattractive due to the journey by ambulance. Extremely difficult transfers from a sofa- with raisers fitted- even with assist of two; often resulting in urinary incontinence for the client. Client passive at this stage and so happy to be home, she is prepared to sit all day and engage in nothing, but wait for carers to call.


Case Management Actions:

  • CM recommends funds are made available urgently to support on a 1:1 basis during work hrs.
  • CM visits client to encourage acceptance of support and the notion that life has more to offer, both in terms of rehab gains and engaging with more than sitting and waiting for care.
  • CM makes recommendation for private assessment from physio, orthopaedic surgeon and OT, as well as considering renting a more suitable property.
  • 1:1 support instated very quickly, using a specialist provider, instantly allowing the client some independence and dignity and the opportunity to engage more fully in community rehabilitation. Dom care calls remain at x 4 per day on a double up basis, as liability between the two providers does not allow co-working.
  • CM co-ordinates a series of private assessments and liaises with statutory colleagues to organise an MDT meeting at the client’s house, share assessment findings and establish overarching MDT goals and individual therapy goals, as well as identifying equipment and adaptations needed as the client does not wish to rent an alternative home.
  • Multiple professionals are involved across NHS, social care and private sectors and CM liaises, reviews progress and addresses arising issues.
  • Ankle surgery is expedited and a pre-surgery MDT is organised following a gait analysis, with client, surgeon, CM and physiotherapist- surgeon comments this was a ’text book’ approach to rehab and surgery and follow up rehab is successful, with client soon requiring only one person to transfer and beginning to walk, as well as making multiple other concrete rehab gains.


Skills used from competency 3:

3a- clinical management- clinical assessment and identifying needs

3b- implementation- Goal setting and monitoring

3c- project management- Organisation and co-ordination of multiple professionals, Active listening regarding home preferences

3d- resourcing- Prioritising needs and available resources

3e- human resources- Understanding the framework support and care providers work within


Positive indicators evidenced:

  • Client central to the process- even though she is initially passive
  • CM is proactive in addressing the lack of rehab and support
  • Client is listened to and needs focus on her remaining in her own home
  • Client achieves her goals and CM actively reviews with the MDT
  • Case manager has knowledge of local resources and services appropriate to the client’s needs
  • CM leads the MDT, maintaining focus on client goals
  • CM is able to prioritise the multiple needs, and address the most pressing first
  • CM monitors costs and liaises with fee payer and providers proactively
  • CM is flexible in using a combination of statutory and private provision to best meet needs


Bear traps avoided:

  • Rehab potential being service not needs led
    • MDT members not sharing common goals and working in silos
    • Funds being spent without clear rehab gains being made and evidenced
    • Client disengaging from rehab due to not having an understanding of her own potential



  • Co-Ordination And Management
  • Duty of care- client focused
  • Personal attributes- leadership
  • Communication- rapport and client buy in to CM process



BABICM Code of Ethics and Conduct in Case Management Practice


Practice reflections:

Prioritising need was important in this case, as there were so many identified, they could not possibly all be met at once.   Client buy in was also key as this lady did not realise her own potential for making gains and was viewing discharge from hospital as her end goal.  The combined use of statutory and private provision meant that rehab could be delivered effectively and in the client’s home environment, but required a high level of leadership and organisation on the case managers part, as well as confidence in their ability from the MDT themselves.