​Jackie Waggott, BABICM advanced case manager and director, Social Return Case Management, writes for NR Times on the challenges of care provision for case managers and clients.

This article considers a range of issues faced by case managers in the provision of care services to clients and highlights the recent British Association of Complex Case Management (BABICM) research which highlights the challenges faced by users of care services, staff, commissioners, providers and coordinators/managers of care. 

​Read the full article here.

​​We need to keep in mind that our role includes evidencing when somebody has progressed to the point at which there is less input needed or where we can start to withdraw. We also need to be aware of progressing to a point where needs have changed and where a change to a different approach may be needed.
 
Goals must be SMART; we need to be smart to communicate them effectively.
 
The smart acronym is a structure for writing goals - Specific, Measurable, Accurate, Realistic, and Timely. Case managers need to tease out these elements in the person's expression of what they want to change and ensure this understanding is shared across the team in order that all interventions are contributing towards meaningful progress and achievements for people.
 
It can be challenging to turn the person's words into a SMART structure and bits of it can get lost. It can often end up being an action plan rather than a goal. It is a skill and an art to be able to articulate what can sometimes be quite a nebulous thing that somebody wants to be able to do into something that you can use as a vehicle to then structure their therapy and input around.
 
Our clients may need support to understand how a focus on a specific area, or that doing things in a particular order or a different way comes from the aspirations they have articulated. This is placed alongside skilled assessment which together with the personal aspirations identify the best path toward achieving their goals. The path may not be smooth. It may require experimentation and trial to establish the most effective way forward. It may not be a direct line from A to B, particularly following complex and catastrophic injury. The client’s aspirations may change over time as progress is made and space is needed for the person and the plan to change and evolve.
 
Inputs, outputs, and outcomes – what is the relationship between them?
 
There is an opportunity in case management to take innovative approaches on an individual basis. We can look at different approaches, clients can access services and methods that may not traditionally be part of rehabilitation and recovery pathways. Social Return case managers support the client and their whole team to try things out and experiment within a framework of clear justified reasoning. There is a wide range of experience within the team of innovative approaches to draw upon. The team is beneficial for clients and as a team member within Social Return - you don't have to have all the answers because you can go to the rest of the team and access that shared knowledge and experience with novel solutions or suggestions.
 
How does this approach help Solicitors, Insurers and Deputies?
 
Solicitors and Deputies can rely on our very client-centric approach. It goes back to each individual unique client. There's nothing more powerful than listening to somebody's own individual story and developing a deep understanding of that person’s experience and aspirations for their recovery and their lifestyle. The context is always the client, and their story informs the approach we take and clarity in the documentation of their progress toward their clearly articulated goals.
 
We are mindful when legal processes are going on in parallel and we don’t lose sight of the need to present a clear picture of the situation, the goals, plans and to demonstrate progress and context. Our job as case managers however is to keep the focus on each individual client.
 
What are the challenges to demonstrate and measure outcomes as opposed to outputs?
 
It is about being very clear and very specific using the SMART goal structure to demonstrate the difference in what has been achieved alongside ensuring context and over time that an accurate picture is painted in the data and information collected. It might be crucial to demonstrate a very small difference, or even that somebody has stayed the same because there are times for specific individuals when not getting worse is a positive outcome. This can feel challenging because you want people to get better but on occasion plateaus can occur, often related to the complexity of the issues that some of our clients have. It is then important to recognise that you managed to keep somebody on an even keel as an outcome. Sometimes that's just as difficult as enabling people to progress.
 
A bit about me
 
I came to Social Return as a result of my longstanding connection and relationship with Vicki Gilman and Jackie Waggott, whom I worked with as an independent occupational therapist for many years. I am now leading the development of the service in the south and the South West of England.
 
I was ready for a new and different challenge that would use the skills that I've achieved and developed over the nearly 30 years as an OT and the knowledge of working with case managers for well over a decade.
 
Throughout the roles and opportunities, I've had, I've always been interested in outcome measures and being able to demonstrate the difference that people can achieve through therapy and having case management and support.
 
My Masters dissertation focussed on outcome measures in community rehab, and I've continued to support the use of SMART goals and outcome measures to share and demonstrate the difference made as people develop and change.
 
If you would like to find out more about demonstrating value, please contact me on the below details. 

​I have always been interested in outcomes and the measurement of change in the people I work with. In fact, I spent quite a few months writing several thousand words on this very subject for my master’s dissertation and the phrase “I love a spreadsheet me” has often been whispered in my presence. Enough said on that subject though.

Looking back on this got me thinking about measuring change – How do we ensure that the people we are working with are fairly represented? How can we make sure that any change is meaningful? How do we demonstrate value and evidence progress?

So, who’s outcome is it?

This is an important question to think about when we consider the significant effort and (all too often) sacrifice that has been made to engage and participate in interventions and activities that are designed to stimulate change. There are “costs” associated with this – emotional, physical, social, psychological, environmental, spiritual, financial etc. etc. We need to remind ourselves of this and not lose sight of the person behind the numbers and graphs – balancing the quantitative snapshot with the qualitative detail of peoples lived experience of change.
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It’s not difficult to translate what we do with people, as case managers, therapists, doctors, solicitors… into numbers to demonstrate that a change has occurred between two-time frames and there are plenty of tools to enable us to do this – 

​​We get a nice graph, everyone’s happy…or are they? Whilst this allows us to compare progress between individuals, professionals, and services, does it compare progress within the person? Does it really articulate what is important on an individual level?
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Being able to communicate change in a meaningful way that makes sense to a wide audience is a skill that is refined over time and developed through discussion and active listening. We don’t always get it right and can lose sight of the person behind the statistics if we are too focused on the numbers and providing data. That’s why we need to gather a variety of information that serves multiple purposes.

​James, put his bicycle back together and was able to do an activity he enjoyed with the person he enjoyed spending time with. He told everyone about his new bike and how he was now cycling with his friend (as well as how much better he felt, how much less pain he was in and how much better he slept – if you asked him and his Dad!)
The physio was able to demonstrate improvements in range of movement, strength, and balance by being creative with standardised outcome measures which were woven into fun activities.

The case manager was able to demonstrate how James was achieving one of his aspirations through participating in Physiotherapy, how he was able to access equipment that continued to contribute to improving and maintaining his physical, social, and mental health as well as preserving social contact and engagement in age-appropriate activities. He was doing better at school - he was able to concentrate more and had an activity that he could talk about and do with others of his own age.

Change could be demonstrated in terms of what James can now do compared with before. We were not just enabling him to achieve improved range of movement in his affected right arm and leg joints, we were enabling him to achieve so much more. We were demonstrating the change made through outcomes and outputs.

Why does it matter that we differentiate between outcomes versus outputs?

Outcomes personalise the “what's desired” and makes it meaningful. Putting the “what” into context for that individual and not just counting the action or the activity, it is about the personal, individual difference that it makes. It's about focusing on what that person does in their widest sense and context and celebrating how close they come to be being able to achieve or exceed in this. It's important to make sure that the things that the person wants to achieve are made very clear and change is viewed through the lens of the intervention or input that's provided to that person. “How does doing X, or providing Y enable P to achieve the thing they have said they want to be able to do, or be able to do differently?”
 
An output is more like counting or quantifying a specific action or activity; service or product provided without necessarily looking at the wider purpose it achieves. For example, consistently providing P with 15 hours of support a week at home is an output. Whereas 15 hours of support a week at home enables P to go out to work 3 days a week and improve their mental health so they are no longer needing to take antidepressant medication.
 
Outputs feed into outcomes and outcomes provide context and meaning – the “so what” which leads onto “what next, and next, and next….”  Outputs are the pieces of the puzzle, and the outcome is parts of or the whole puzzle.
 
Demonstrating Value

Value is a personal, individualised concept and will mean different things to different people. That is why it can be quite difficult to quantify where several parties are involved, and they are often seeking different examples to demonstrate that value has been provided.
 
In order to achieve this, we need to understand what the expectations are. Sometimes these will be less achievable or less realistic – that does not mean that attempts should not be made to work towards them as there is nothing better than being proved wrong.  Often it is about compromise in such situations and aiming to understand the importance behind expectations and the meaning placed on the aspiration. This then helps in being able to think creatively and proactively about what value means to the different parties and what their needs are from the information we provide.
 
This also links back to being clear and distinguishing between outputs and outcomes as well as devising a clear plan to work towards the desired achievements. This plan needs to articulate what the person will be doing differently rather than a list of actions or tasks that have been completed.
 
Seeking feedback on the information provided will also ensure that there is not a mismatch between what was expected versus what was provided.
 
At Social Return, we provide regular updates and ask for feedback to continually maintain high standards of communication and transparency in our case management activities. We like to be challenged and consider this an important part of our role to achieve the best outcomes for the people we work with.
 
If you would like to find out more about outcomes and value, please contact me on the below details. 
​

We are at an exciting time in neurorehabilitation - we are discovering more and more about our brain and nervous system and how we can adapt to life-changing injuries by harnessing the potential of technology to push the boundaries of what is currently possible.

Our previously unseen electrical and brain activity can be enhanced to enable us to visualise our emotions, communicate when we can’t speak, lift limbs that we have difficulty moving.  We can be transported to far off, fantastical lands from the comfort our armchairs by putting on a VR headset, and exercise on a treadmill without being able to walk.

This is not just the stuff of Hollywood movies and fantasy novels, but real life that can be seen, touched and used in rehabilitation centres across the world right now…

So, how do we ensure that this technology is accessible, appropriate and enables the people using it to achieve their goals and aspirations?  How we do prevent exoskeletons from gathering dust in cupboards or the corners of therapy rooms? How do we justify and prove that these technologies make a difference and are worth the investment?

Firstly we need to keep in mind who the technology is for. We are adaptable, complex systems that require varied, intensive, targeted opportunities to refine and improve our abilities.  We know about “practice makes perfect” – practice needs to be the right amount, in the right place, at the right time… for a purpose and have meaning, not necessarily helping us achieve perfection. One size definitely does not fit all.

Secondly we need to coproduce, collaborate, and cooperate to share knowledge and skills – it is essential the end user is part of the team.  It is totally possible to repurpose and adapt current technologies that are already in use such as robots and VR games for the rehabilitation market.  What works in one setting does not necessarily work in others. It is a great opportunity to design and manufacture technology that is fit for purpose, which can be updated and upgraded and recycled.

Thirdly, we will still need therapists and case managers.  (You probably think that this is because I am one…”so you would say this wouldn’t you”). Technology is not a magic bullet and will not replace therapists or therapy or the need for case management.  It will enable more people to participate in high dose, high quality rehabilitation that is commissioned by case managers and structured by therapists as part of their individual rehabilitation programme.  Therapists need to be open-minded and given access to systems and training that enables them to use their clinical reasoning to consider technology as a viable option as part of their treatment plan. Case managers need to keep up to date with innovations and technologies by networking and sharing information so that our clients have the possibility of being able to access neurotechnology now and in the future when this is appropriate.

Lastly, technology has the potential to transform the rehabilitation experience of people affected by life changing injuries and our understanding of the brain and nervous system. By trialling available technologies with people who may benefit from them and being able to demonstrate tangible changes in function – enabling people to thrive, not just survive – we have the potential to create a very different future for all of us.
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If you are curious about neurotechnology and how it could benefit your clients and services, get in touch.  I would welcome the opportunity to explore this further and share my experiences with you.

​Click Here to find out more and to watch the first interview in the series with Dr Melanie Lee, Clinical Psychologist and Director of Trust Psychology.

We would like to update you from the team here at Social Return in light of the COVID-19 outbreak in the UK, the government and NHS guidance for us all and the additional need to protect those particularly vulnerable.

In relation to our clients we have undertaken risk assessments on an individual basis, including seeking information on the policies and procedures from the individuals and services working with each of our clients. We are mindful of the need for support for some of our clients and families to respond to and cope with the current situation, particularly as it develops and the advice is updated. In terms of client visits, we are evaluating on a case by case basis if there is a need for essential contact in a physical form, inevitably there is often more than one way to achieve the outcome required. This is resulting in less face to face visits, but more in the way of remote contact by text, phone and video calls. 

Our approach ensures the highest level of safety for our clients, staff and their families and we have the flexibility from skilled experienced individuals to cover any time of sickness or isolation within the team. This ensures that there will be no pause or misstep for clients. We are also able to take on new referrals at this challenging time and work creatively to assess and support clients and families.

The Social Return team are working from home - our case managers often do some home working and so we are well set up for this. Timing-wise we were very ready for this in every way, not because we had a crystal ball but because we have been gearing up for expansion over a wider geographical area. We use a range of platforms and resources to ensure we can access tools integral to our way of working, we have a remote system of staff support, supervision, shared information and a bit of virtual office-fun to ensure the team continue to enjoy the challenges their jobs bring and that they feel enabled, supported and part of something.

I hope the information here is reassuring and as positive as it can be under the unusual circumstances we find ourselves in as a nation, indeed as a world. I thought I would share with you something that was said in an internal meeting here earlier this week - a team member said, "What we do is to work in many unique challenging situations, supporting people through difficult times and balancing their needs - and this is exactly that." 

Do please keep in contact with us, all our contact details remain the same and you should expect the same swift responses and creative thinking that you are used to from us. If you have any particular concerns do let us know and don't hesitate to call me personally if I can be of any assistance.

With kind wishes and healthy thoughts.
​

The British Association of Brain Injury Case Managers (BABICM) ‘Life of Brian’ event, will be held on the 8th October in Leicester. This event offers an unmissable 'real-life' scenario, offering step-by-step advice for brain injury and complex care professionals as well as deputies and litigators. Follow Brian on his journey from birth through his teenage years to adulthood and share in his experiences after being born with a brain injury.

BABICM have recently announced the full programme for this exciting event.

BABICM members are eligible to access a range of special offers for this event, including the earlybird discount which ends on the 27th September 2019.

Resilience is an ability to be successful both personally and professionally, in a high-pressured, fast-paced and continuously changing environment. It’s fair to say that this is a reasonable reflection on the landscape within case management where the environment does indeed change continuously.

Although undoubtedly sometimes stressful, the majority of case managers find their work deeply satisfying, despite inevitable emotional burdens of working with clients closely on emotive and difficult subjects. As a team at Social Return Case Management we endeavour to support each other in our working relationships and celebrate the achievements of each other and our clients.

Building Resilience as a Resource

Case management requires the staff team to individually and collectively be able to draw on all areas of experience to maintain a healthy balanced perspective and sustained energy and stamina in meeting challenging goals. This underpins the success of our clients in achieving their goals along the rehabilitation pathway.
 
Personal Resilience relies upon an ability to demonstrate confidence, adaptability and flexibility. As a company therefore we select staff who have these skills and are also keen to develop themselves further to benefit the team.
 
Part of having personal resilience relies upon also having organisational resilience. This is why Social Return puts a focus upon demonstrating support, trust and mutual respect of business and personal priorities as well as experimenting with new ways of working to better meet business goals and personal needs.
 
A key element of the model of our business which exemplifies this, is working in teams, utilising the skills of assistant case managers, other case managers via peer supervision and the client liaison team. This allows for additional flexibility, sharing the burden and also adding additional skills in to the mix – an example of practical ways the organisation can build integral support to enhance resilience on a personal level.
 
We recognise that the attributes of a good support network within the company are:

• Accurate empathy
• Reflective ability
• Optimism
• Emotional intelligence/literacy
• Self-awareness
• Self-efficacy
• Social confidence
• Sense of humour
• Work-life balance

 
Emotional Intelligence

Emotional resilience is closely related to emotional intelligence and emotional literacy - the ability to recognise understand and appropriately express our emotions.
 
Emotional intelligence helps our team to manage their own emotional reactions and those of others more effectively, and to recognise the potential impact of their personal emotional states on their problem-solving and decision-making abilities.
 
Goleman (1996) identified the five 'domains' of EQ as:

• Knowing your emotions
• Managing your own emotions
• Motivating yourself
• Recognising and understanding other people's emotions.
• Managing relationships

 
Emotional intelligence is a skill absolutley necessary for case managers because of the diversity of their work, the multiple stakeholders they have to deal with on daily basis, and the increased potential need for conflict management. Emotionally intelligent managers understand their own behaviour, their strengths and weaknesses. They are calm, in control and are highly attuned to the emotions and feelings of others. They seek to enhance unobtrusively. Subsequently, they make strong connections with people and know how to react in different situations, knowing what to say and do to make others feel better and what it takes to influence or inspire them.
 
Top 5 tips to build resilience:
​

1. Set 15 minutes a day aside for reflection, taking this time will encourage feelings of calmness and control
2. Observe your team closely. Make an effort to notice how people are feeling and thinking.
3. Be empathetic. You may not feel the same way as others do, but you might have experienced the same emotions in another situation. Use this experience to show empathy.
4. Have the courage to be wrong. Admitting mistakes and learning from them shows good character and integrity.
5. Listen and be open to suggestions. Showing that you are interested builds trust and encourages better, open communication.

In these cases, having an ability to know what the client would want to happen in any of the events life throws at them is crucial. Despite always holding the best interests of the client at heart, the case manager co-ordinates support and intervention, there are many conflicting roles which may get in the way of truly advocating for the client. On these occasions it is necessary to have someone in the MDT whose only role is to represent the client’s voice.
 
It is sometimes necessary to consider which role might be most suitable to represent the client’s voice. Whilst and IMCA is available to anyone who lacks capacity and is unbefriended (that is, they have no relative or friend that it would be appropriate to consult with about those decisions), an advocate may be more appropriate and a closer look at the roles helps in making that decision. It is unusual that a client would require the services of both an advocate and an IMCA simultaneously.
 
What do IMCA’s and Advocates do?

• support and represent the person in the decision making process
• find out the person's past and present wishes, feelings, values
• evaluate information including accessing and copying relevant social and medical records
• evaluate alternative courses of action
• consult with others involved in the person's life
• seek a further medical opinion if necessary
• check the Mental Capacity Act principles and best interest check list are being followed
• prepare a report, which the decision maker has a legal duty to consider
• challenge the decision (including capacity) if necessary, informally first and through Court of Protection as a last resort

 
Role of the IMCA

The Mental Capacity Act 2005 introduced the role of the independent mental capacity advocate (IMCA). IMCAs are a legal safeguard for people who lack the capacity to make specific important decisions including making decisions about where they live and about serious medical treatment options.
 
In particular, and IMCA should be instructed  where there is a serious exposure to risk, for example:

• Risk of death
• Risk of serious physical injury or illness
• Risk of serious deterioration in physical or mental health
• Risk of serious emotional distress
• Where a life-changing decision is involved and consulting family or friends is compromised by the reasonable belief that they would not have the person’s best interests at heart.
• Where there is a conflict of views between the decision-makers regarding the best interests of the person.
• Where there is a risk of financial abuse which could have a serious impact on the person at risk's welfare.

 
The IMCA role would be focused on the protective measures being considered and is likely to end when decisions have been made regarding these.
 
Role of the Advocate

Like and IMCA, Advocates provide a crucial role in assisting people to express their views and wishes, secure their rights, access information and to be involved in decisions that are being made about them and their situation. This is however a wider reaching role than safeguarding and protection, and can be relevant to many life decisions that a client faces.
 
When a client is unable to share their wishes, an advocate’s role is to collect and represent the person’s prior expressed values and beliefs. Using this information they will then ascertaining proposed courses of action in order to share these with the MDT.
 
Concluding Remarks

Our clients benefit from the statutory provision that the IMCA brings but sometimes the role is not far reaching enough in the context the litigation process. There are often complex and ethical decisions to be made with the view of returning the client back to as close as they can be if it were not for the index accident, which are out-with the role of the IMCA. On these occasions a specialist Advocate experienced in working with this client group can be incredibly beneficial for all involved in the MDT.