Case management is the coordination of community services for people by a nominated person who is responsible for the assessment of individual need and the development and implementation of agreed care plans. It is required for individuals who have a serious illness and need ongoing support; however across the UK there is very little provision for children and young people recovering from an acquired brain injury. We know this results in significant ongoing inequalities for individuals with regards to their future health, education and social needs. In turn this can affect the ongoing physical, emotional, psychological, social and financial well-being of individuals. Matrix has therefore developed its Case Management Service to provide for these children with the aim of reducing long term inequalities.
Our process is the same for everyone – it is a fully integrated joined-up approach. In simple terms it can be shown as follows:
This means finding out as much as we can about the child or young person and their life before the injury. Then we find out about the accident and the cause and nature of the acquired brain injury. Only after this happens can we start to fully understand ALL the rehabilitation needs of the child or young person so that we can find the right solutions to the all the problems; not just some.
We also look at the family unit because ultimately it a loving, caring, interactive and dynamic relationship between different people. We understand the trauma the family have faced and how the wellbeing of one member significantly impacts on the wellbeing of everyone else. The early medical treatment and nursing care provided for a patient with an acquired brain injury is extremely stressful with many unknowns and even fewer guarantees. So our Case managers also include the family unit as a whole in the process – because we understand what you have been through and how hard this is.
Complex problems sometimes require innovative approaches to find the right solutions. But if you don’t really understand the problem, how can you find the right solution?
Finding the right solution sometime means thinking outside the box and applying trusted methods in different ways. Or using well known tools for different purposes. Creativity and innovation is sometimes the key to solving complex problems and that will bring about the required change. But that doesn’t mean it has to be complicated either.
Our Case Managers are experienced, skilled and confident in applying well-practiced techniques in new and innovative ways with the sole purpose of aiding an individuals’ recovery and facilitate improvement. Sometimes this also means bringing in other people from different organisations if we think they can help, which means you always have the right people working with you without you having the pressure and stress of having to go out and find them yourself.
Of course we work with both the child and the family because we know how important it is for you to be involved and included. After all – you know your children better than anyone. Our role is simply to help and support you and offer the right solutions to the challenges that have come about as a result of the acquired brain injury. Our Case Managers therefore work with you to agree a structured way forward and support you to recover from your ordeal and re-establish new family routines.
The plan will set out clear rehabilitation aims, objectives and outcomes and will set out key review points at which progress can be measured.
Once we have agreed the forward plan and the approach the rehabilitation plan will take, our Case Managers will ensure that the right people with the right skills are brought in to deliver what is needed to meet the needs of the rehabilitation child or young person in accordance with the Rehabilitation Plan. We take a team-based approach and the Case Manager takes on the role of the Team Leader; giving direction and support to the team where required. This ensures that the work everyone is doing is coordinated and they are all working to the same plan. Only by working together as a coordinated team can the agreed goals in the rehabilitation plan be realised. Regular team meetings will happen to ensure the rehabilitation plan is being delivered as agreed and the Case manager will ensure family members are regularly included and updated on progress.
As with any change process it is important that progress is monitored and recorded. With neuro-rehabilitation this is even more important. We understand the psychological impacts of recovery and how important it is to know you are making progress. Whilst the neuro-rehabilitation journey is different for everyone, we think all progress – no matter how big or small – should be measured, reported, recognised and celebrated. All our rehabilitation plans will set out key review points to ensure progress is being made. This will not always be significant and may temporarily stall (plateau) for a while and we understand how disheartening this can be. At this point we think that a reflection of the journey made so far is often the key to maintaining a positive attitude for the tough times ahead.
At this point a collective decision will be made as to whether the plan and the agreed goals need to be revised either up or down and over the short, medium or long term. Neuro-rehabilitation is a complex journey and needs to be adaptive and flexible to ensure continued commitment and improvement. This can be hard but whatever the outcome the decision will be made together and with the input of the family and the whole support team.
Whatever the outcome of the previous Step the rehabilitation plan will be updated or revised to reflect what has been agreed. This then becomes the ‘new’ working rehabilitation plan document until the next key review point. Whatever the outcome of the previous step – we continue to support you for the ongoing long journey ahead. Our priority is to help the child or young person to be the best they can possibly be and help and support the family to ensure they can.
"Intensive and individualized approaches work. A one-size-fits-all approach doesn't. You have to make it relevant to the child."
"Case management for children and young people post acquired brain injury is 'pivotal' to successful outcomes and must be local"
"Pediatric neuro-rehabilitation cannot be delivered in isolation. The needs of the child have to be looked at both holistically and within the context of the family unit. Parents need to be empowered to be parents in post-acute pediatric neuro-rehabilitation following brain injury"
"Children and young people have poor social competence post brain injury due to reduced cognition, executive functions, and emotional control. As a result they are twice as likely to have mental health issues in the future"
"Families and professionals spend time focusing on the negative aspects of ABI. Families need to be properly supported as 'resilience' is key to delivering successful outcomes for children and young people."
"Parent-supported interventions following pediatric ABI bring reductions to the cost to society"
"NHS clinicians struggle with what intervention to priorities in pediatric neuro-rehabilitation due to limited clinical time and the complexity of needs. Children, clinicians, parents and schools all have different neuro-rehabilitation priorities"
"Thousands of children and young people living in the UK today without the help and support that can make a huge difference to their lives"
"Restoration of anatomical functions and relationships must be done within 2 months of brain injury"
"Too often children and young people with ABI are discharged from hospital without specialist brain support that they and their families need to overcome lifelong challenges"