Case Management

What is Case Management?

Case management is the coordination of community services for people by a named person who is responsible for the assessment of individual need, and the development and implementation of agreed support plans. It is required for individuals who have a health need or a complex disability and need ongoing support to facilitate recovery.  However across the UK there is very little FREE provision for children and young people recovering from an acquired brain injury; particularly for cognitive rehabilitation therapy.  Statistics show that children from poorer backgrounds, have poor long-term outcomes.

It is also assumed that neuro-rehabilitation happens in schools, but from experience, we know this to be untrue.  Teachers are not trained in neuro-rehabilitation interventions; nor do they understand acquired brain injury and the changed needs of the child enough to facilitate a good recovery.  We know that a child returning to school with memory problems, will leave with memory problems. Ignoring their functional impairments does not make them go away, but Cognitive Rehabilitation Therapy and Specialist (Rehabilitative) Education Support can make a huge difference.

Over time, a lack of appropriate support results in significant ongoing inequalities for individuals regarding their future health, education, employment and social needs. In turn this can affect their ongoing physical, emotional, psychological, social and financial well-being of individuals. We think these children and young people deserve better!   Matrix has therefore developed its Case Management Service to provide for these children and young people and their families with the aim of reducing long term inequalities.

The Process:

Our process is the same for everyone – it is a fully integrated joined-up approach. In simple terms it can be shown as follows:

Step 1: Assess Needs

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 Manager also include the family unit as a whole in the process – because we understand what you have been through and how hard this is.

Step 2: Develop the Plan

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 Manager is 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. After all, as a parent, she had to do this for her own child.

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.

Step 3: Implement the Plan

Once we have agreed the forward plan and the approach the rehabilitation plan will take, our Case Manager 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 ensure the rehabilitation plan is being delivered as agreed and the Case Manager will ensure family members are regularly included and updated on progress.

Step 4: Review (& Revise) the Plan

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 support plans 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 the Progress Review Meeting 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 clear, adaptive and flexible to ensure continued commitment and improvement. This can be hard but whatever the outcome the decision will be made together with the family and the whole support team.

Whatever the outcome of the Review, the support plan will be updated or revised to reflect what has been agreed. This then becomes the ‘new’ working support plan 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.

"Our 10 year study proves that family-led home-based neuro-rehab interventions deliver the best outcomes for children and young people"
Lucia Braga; Brazil
"When someone has a brain injury, early access to local, specialist rehabilitation is crucial to ensure the maximum recovery and make significant savings to the state in health costs"
Headway; United Kingdom
"Different 'experts' involved in paediatric neuro-rehabilitation come from different organisational cultures which causes conflict and has a negative effect on the outcomes for the child."
Barbara O'Connell; Ireland
"We are impressed with the progress you have made with the individual we referred to you."  Social Worker    
"Intensive and individualized approaches work. A one-size-fits-all approach doesn't. You have to make it relevant to the child."
Recolo; United Kingdom
"We are medical practitioners. The real experts are the parents. Over the last 35 years they have taught me everything I know"
Lucia Braga; Brazil
"We need to harness the power of brain plasticity for treating children and young people with brain injury, especially at the key ages of 0-3 and at ages 10-16"
Professor Bryan Kolb; Canada
"NHS clinicians struggle with what intervention to prioritise in paediatric neuro-rehabilitation due to limited clinical time and the complexity of needs. Children, clinicians, parents and schools all have different neuro-rehabilitation priorities"
Recolo; United Kingdom
"Brain development is complex and prolonged. Brain plasticity is influenced by a range of factors. Plasticity provides a base for neuro-rehab therapies and treatment"
Professor Bryan Kolb; Canada
"My colleague was blown away by the tremendous work your organisation is doing for society."  Social Worker

OUR MISSION: To work to remove inequalities for children & young people affected by acquired brain injury; and provide effective support to their families that makes a real difference.

Council for Disabled Children Community Funded Charity Excellence Lottery Funded Youth Foundation BBC CiN