Helping a client make big life changes

By Gill Dunn, Case Manager, Cheltenham

I am always asked ‘What does a case manager do?’ I have to stop and think, ‘what do I do?’ as every day is different, but I suppose the short answer is ‘whatever it takes’!

I recently gave a presentation and this same question came up. In response, I quoted the ‘Case Manager’s Creed’. If you are thinking of becoming a case manager you should read it – it says it all. Before writing this article I read the creed again and realised I could tick every box, especially in the last 7 months…

Towards the end of last year, I saw one of my clients ‘going downhill’ and becoming increasingly frail, but refusing help. This is not unusual, especially when someone has been so independent in their own home, and as a case manager my role was to be caring, supportive and understanding of my client’s wishes, feelings and frustration, as it became evident he was no longer able to live on his own.  I could see he was not looking after himself, but as any case manager knows, mental capacity is one of the first things to be determined, before diplomatically trying to ‘persuade’ the client to reconsider their living situation. My client did have capacity in this area and wished to remain at home without help. Unfortunately, an incident shortly before Christmas resulted in him being hospitalised and unable to return home.

This is when I had to become assertive, or ‘bossy’, as my friends would say. I came straight to the point, explaining to him why he should not (or, to be honest, could not) go home and, to my surprise, he agreed. He didn’t want to go back home and understood that he needed support. At this point I had to put my thinking cap on… Where do we go from here? What would I do if this was a family member?

My immediate priority was to find a safe and caring respite placement, where he could have his privacy and enjoy a nice Christmas, while at the same time thinking about his future. Prior to his hospitalisation, my client’s deputy and I had both (very diplomatically) suggested downsizing and moving to a retirement flat, where he would still have his independence, but with support. He wasn’t interested.

I put the idea to him again when he moved into his respite placement. This time he agreed to the idea, so I got ‘on the case’! After looking at several flats in the retirement complex, we finally agreed on one, all the time keeping my client up to date, involving him as much as possible and keeping his family in the loop, as they were happy for me to manage it all.

It was then that the true “whatever it takes” nature of the case management role came into full effect.  I became a buyer and seller, interior designer, personal shopper, house clearer, liaison officer, carer, transporter, finder of painters, electricians, a handyman, equipment, therapists… the list goes on and on and I am sure I have forgotten a lot of what I did and continue to do.

I was determined to have the flat all set up, so that when he walked in the door for the first time it would feel like home. For a month I ran around like a headless chicken, buying furniture, buying the equipment the OT had recommended, having the rooms painted in the colours he chose, introducing a physiotherapist to help with his mobility, arranging for an automatic front door and automatic lights to be fitted and getting aids and adaptations in place, so my client could be as independent as possible.

Lastly, but crucially, I introduced the support team. The team already worked at the retirement complex and had supported individuals with brain injury, so they understood my client’s needs, which did make life a bit easier.

By the time my client moved into his flat in the spring, everything was in place and ready for him, and I’m delighted to say that we have now reached a stage where he is settled, happy and healthy.

Finally, even though we don’t do this job for praise or glory, it’s nice to know people appreciate what you have done. My client’s family thanked the ‘team’ involved which made me smile as the team was ‘me’, but my client’s deputy made me smile even more when he said –

As you recognise, all this has been achieved through Gill’s tireless work and dedication.

Whatever it takes!!

Do you want an exciting new challenge? We are looking for experienced clinical professionals in the North West, North East and East of England to join our nationwide team of case managers.

We pride ourselves on our reputation for providing the highest quality case management service and we are looking for a highly motivated and enthusiastic case managers who share that commitment, to join our dynamic interdisciplinary team.

Read our Case Manager Job Profile and contact us for more information

Congratulations to Steve Pimm on becoming a BABICM Advanced Member!

We’re delighted to announce that following a successful peer review, Steve Pimm, our Senior Case Manager based in Bury, has been awarded Advanced Membership of BABICM (the British Association of Brain Injury Case Managers).

Steve, who celebrates his 5th anniversary with Rehab Without Walls this month, is a physiotherapist by background, with over 20 years’ experience working in the field of brain injury.

In a recent survey, one client’s deputy commented;

Steve is a very knowledgeable and approachable case manager. I have recommended his services to colleagues. Steve is directional when needed, but at the same time displaying the correct amount of empathy.

Congratulations Steve, and Happy Anniversary!

Congratulations to Kate Lewis, who has just become a BABICM Advanced Member!

We’re thrilled to announce that Kate Lewis, our case manager based in Tamworth, has passed her peer review and become an Advanced Member of BABICM.

Kate, who has been with Rehab Without Walls for 3 years, is a paediatric nurse by background and also has extensive experience in managing care packages.

In a recent satisfaction survey, a financial deputy said;

Kate is a fantastic case manager who shows empathy towards her client as well as adopting a professional “can do” attitude. She is approachable and goes the extra mile to ensure there is a good rapport with her clients. I would feel confident in recommending her to other clients.

Well done Kate!

On Friday 12th September 2014 Rehab Without Walls presented a successful conference for invited guests entitled “The Long and Winding Road: Case Management and Rehabilitation in the Community” to celebrate our 20th birthday.  The conference celebrated Rehab Without Walls’ achievements, and outlined the importance of focusing on improving the quality of what we do, looking constantly at how we do things, and asking whether they could be done differently or better.  Speakers at the conference included Rehab Without Walls Directors (Dr Neil Brooks & Ms Cathy Johnson), Senior Judge Lush of the Court of Protection, Chris MacDonell, Managing Director of the Medical Rehabilitation Division of CARF (Commission for Accreditation of Rehabilitation Facilities), Dr Nathan Cope (Founder and Senior Medical Officer of Paradigm Management Services, USA), and our long term colleagues, Hugh Jones, Managing Director of Hugh Jones Solicitors and Yogi Amin, Head of Public Law Department, and Julia Lomas, Head of Court of Protection Department, both of Irwin Mitchell Solicitors.

CARF accreditation & CQC “outstanding” status

The conference gave an opportunity to reflect upon the formal steps that we had taken to continue to improve the quality of the services we provide.  One of the most important steps was our decision to seek CARF Accreditation.  We had thought about this for 3 – 4 years before formally deciding to seek accreditation, and achieved our first full three year accreditation in September 2009.  Each accreditation runs a maximum of 3 years.  We are currently on our third accreditation sequence.

Our early discussions about CARF led us to think more deeply and fundamentally about the maintenance and continuing development of quality services, and we made a decision to seek registration with the Care Quality Commission (CQC).  This was not a statutory duty upon us, but we felt that to seek CQC registration would entail additional external scrutiny in a UK context, which could only have a beneficial effect upon our service delivery.  We have now been CQC (previously CSCI) registered for 11 years, and have just (25/04/16), received the report from CQC following their review of our services on 15th January 2016.  The review was extensive and intensive, involving scrutiny of our documentation, as well as interviews with key stakeholders. We obtained an “Outstanding” overall report.  CQC assesses quality in five areas (is the service safe, is it effective, is it caring, is it responsive, and is it well led?).  We received “Outstanding” status for safety, and for being well led, which led to an overall rating of “Outstanding”.  We are delighted that our commitment to quality is recognised by this official UK body.

Why does this matter?

Accreditation from CARF and scrutiny by CQC forces and supports a thorough review of all aspects of our practice, including how we manage our clients, how we recruit, train, and develop our staff, and how we manage ourselves as a successful and ethical business.

Seeking accreditation and scrutiny from organisations like CARF and CQC does a number of things, but there are two which have particularly impressed. First it forces an organisation to do the things which the organisation wants to do, genuinely intends to do, but somehow keeps putting off.  The second is that the nature of the in-depth analysis of the business both in terms of scrutiny of documentation, and, crucially, a two day masterclass examination by two CARF “Surveyors”, acts as a flashlight investigating every area of our practice, finding problems, and, just as importantly, finding examples of good practice.  Indeed, we are delighted to have been recognised for “Exemplary” conformance to standards for the quality of our approach to risk management at our CARF surveys in 2009 and 2012 and for our use of the BABICM competency framework in 2015.

Rehab Without Walls was the first practice in the world to be awarded CARF accreditation for combined adult and paediatric brain injury case management and for nearly 6 years, we were the only case management organisation in Britain to be accredited.

CARF, while based in America, accredits rehabilitation organisations from the earliest acute hospital care to long term community based slow stream rehabilitation throughout the world.  CARF Accreditation is being increasingly sought in Scandinavia, in the Arab world, in the rest of Europe, and, more recently, in China.  We are part of a very large and growing family devoted to quality.

APIL and the Rehabilitation Code 2015

Clearly, Rehab Without Walls is not the only organisation to feel that CARF is very important for quality assurance.  The APIL publication (Think Rehab! Best Practice Guide on Rehabilitation – 3rd Edition), dated April 2015,  gives detailed and helpful guidance on all aspects of rehabilitation, from understanding the need for and nature of rehabilitation, to choosing a rehabilitation provider, organising an Immediate Needs Assessment, and finding a case manager.  APIL notes that the appointment of a case manager is critical, particularly in high value compensation cases, where a case manager can make a substantial difference to outcome.  However, APIL rightly, asks the formal question, “How to identify the skilled case manager?”.  The authors of the “Best Practice Guide to Rehabilitation” acknowledge that there is no accreditation system for case management in the UK, “although we note that there is a very helpful competency framework and standards document developed by the British Association of Brain Injury Case Managers (BABICM), which we have found extremely helpful in staff supervision and staff development”. The guide comments that

“There is a Commission on Accreditation for Rehabilitation Facilities (CARF) an accreditation body with an extensive and growing international remit. The standards match the functions of a case management company more closely than PAS150 in that they focus on clinical and rehabilitation activities in addition to solid business practices.”

and goes on to conclude that

“the preferred framework for case management companies in the UK may be CARF accreditation.  There are only two case management companies that have this certification”.

It is always nice to feel that one is ahead of the curve!

Finally, 2015 saw the publication of “A Guide for Case Managers and those who Commission them”, published alongside the new Rehabilitation Code 2015, active from 1st December 2015.  The guide considers the issue of how to select a rehabilitation provider or case manager, and suggests that one of the key questions that should be asked is “do they have external accreditation with a recognised body such as CARF …”.  We are delighted to be able to answer in the affirmative.

We do feel very proud that we have external validation and recognition of our quality both nationally and internationally.  We are extremely aware that we could not have achieved the quality levels which we have without a skilled, experienced, and dedicated team of case managers, and an equally skilled, experienced, and dedicated team of support staff who keep us functioning day after day, week after week, and year after year.  Without them, we would not have achieved what we have, and we want them to know how valued they are.

…And so the journey continues. Looking forward to our next CARF survey, due in 2018, we are as committed as ever to ensuring that our practice continues to stand up to scrutiny, as the bar is raised, quite rightly, ever higher.

Dr Neil Brooks

April 2016 

CARF logo

What is CARF?

CARF stands for the Commission on Accreditation of Rehabilitation Facilities.  It is an international organisation based in the USA, and is a “not for profit” company that accredits healthcare services across four continents. In the USA, the CARF accreditation is a badge which is used to secure funding from governmental funding organisations. In this country it is used as a clear indication that the organisation provides excellent healthcare services.

Currently more than 50,000 programmes and services at 23,000 locations can say that they meet the standards required by CARF.  More than 8,000,000 people of all ages are served annually by CARF accredited service providers.  CARF is a global organisation which extends to countries in North and South America, Europe, Asia and Africa.

The standards for good practice set by CARF cover both business and clinical areas of practice.  There is a core belief that clinical excellence should be backed up by high business standards to ensure financial sustainability and the resources to support the clinical process. The business standards also cover issues such as managing risk, managing the workforce and measuring performance. CARF puts the client at the centre of all of its standards.

How does the CARF survey work?

One way in which CARF stands out from other accreditation bodies is the fact that CARF surveys are carried out by experienced professionals who are independent and not employed directly by the CARF organisation. CARF surveyors all have day jobs working for other organisations in the field. This makes the process a true peer review process and ensures that the people carrying out surveys have an understanding of real world situations and can provide meaningful up to date advice based on real practical experiences.

All surveyors take time from their usual employment to visit units aspiring to become accredited, or to retain their accreditation.  They apply the standards and measure performance against these standards, and in addition, offer consultation and advice based on their experience and experienced gained in surveying other units.

To become accredited, organisations have to undergo a two or three day survey process in which two or more surveyors visit the unit and carry out tours, look at documents, interview staff and people from outside the organisation. Enormous amounts of information are reviewed by the surveyors during the survey to assess compliance with all of the required standards.

When done properly the survey is a positive constructive experience for both the organisation and surveyors.  It involves the sharing of ideas in an atmosphere of mutual respect.  At the end of the survey the organisation is presented with three lists; a) strengths, b) recommendations i.e. areas of practice that do not meet the required standard and must be put in place before the next survey and c) consultations i.e. suggestions made by the surveyor that could improve working practice which the organisation is not required to implement.

Organisations can be given 1 or 3 year accreditations depending on their compliance. A 3 year accreditation is evidence that the organisation is working at a high level of excellence, being compliant with the vast majority of standards.

My role as a CARF surveyor

In 2009, I was invited by CARF to train as a surveyor. Since then I have travelled to the USA (and on one occasion to New Zealand) every year for one week to complete two back to back surveys.  I view this as a privilege to be invited into many and varied high quality organisations providing excellent services and given free access to their documents, systems and expertise.

During each survey, staff at the organisation provide enormous amounts of information, both written and verbal, explaining exactly how their organisation works and how they achieve their outcomes.  Surveyors are given the opportunity to view areas of strength and also areas in which improvements can be made.  We are also given the opportunity to share our own experiences and provide consultation to these organisations.

Clearly also it is an invaluable opportunity for surveyors to learn how other organisations work and achieve their outcomes.  From my own perspective, coming from the UK, it also gives an interesting insight into how the US Health Service operates and comparisons are always made with our own system in the UK.

Due to my own clinical experience, I am usually invited to survey specialist acquired brain injury programmes and am able to cover inpatient, outpatient, residential settings, vocational rehabilitation, and case management services.  It is interesting to note areas in which US Healthcare organisations are stronger than in the UK, but also to see areas of practice in which we are stronger.  For example, one area in which Rehab Without Walls outperforms all of the many excellent services that I have surveyed in the USA, is the area of risk assessment.  Despite their litigious culture, the US service providers consistently lack an effective means of documenting risk assessments.  This is an area in which I am often able to provide consultation and advice.

A clear benefit of my involvement with CARF and my experiences visiting other units, is that it confirms the fact that we, at Rehab Without Walls, provide an excellent service.  Rehab Without Walls achieved three year accreditation with CARF in 2009 and 2012 and we are due to be surveyed again later this year.  Achieving CARF accreditation is by no means easy and requires a service to be working at a very high level in both clinical and business areas. However the rewards are great, as are the rewards of being a surveyor.

Steve Pimm – Senior Case Manager