Case Management Services (CMS) was registered as a company in 1988, set up by Bill McKinlay and Neil Brooks[i], both neuropsychologists. We were aware from experience that for many people who had sustained TBI there was little rehabilitation available. Where rehab was available it was often in an inpatient unit, which gave individuals with TBI little chance to practice the skills/methods learned in rehab to their own environment.
Rehab is part treatment and part education. Treatment will aim to remove or reduce obstacles to progress, like pain, sleep disorder, anxiety, and so on. Beyond that the process is educative – learning ways to work around memory and executive impairments; developing a new perspective on life; and planning and developing skills and interests that play to the strengths the individual has retained or new skills learned.
In 1988 there was much less rehab in both Scotland and the UK as a whole. In Scotland the Astley Ainslie Hospital provided the main centre of specialised neurorehabilitation with no such centres in Glasgow, Dundee, or Aberdeen. Nowadays, of course, there are specialist centres/services in all these cities as well as in Fife, Ayrshire, Inverness, and elsewhere. Not only was there less rehab, but access for people who had TBI to rehab or any kind of help was much more limited.
A medico-legal case in Scotland marked a step forward for families of injured individuals when the judge directed that it was not enough to leave the care/support of the injured person to the wife (despite marriage being “in sickness and health”) but that some financial provision for care/support should be made. No evidence had been led as to how much was necessary, and only a small one-off payment was provided, but it did establish the principle that provision should be made. The case showed that there was a need to lead evidence on the costs of future care/support/etc and the practice of preparing Needs or Quantification reports has grown accordingly. These costs nowadays include costs of rehab and case management; care/support; equipment; and extra living costs; as well as costs of guardianship where necessary, loss of earnings, extra accommodation needs, etc.
In parallel with these developments, the idea of case management was becoming more attractive in neuro-rehab. Originating in the US, the version in this country was clinically led and aimed to provide the individual with TBI with neuro-rehab and if necessary ongoing support in their own home. The lessons learned in rehab could more easily be put into practice living at home, and links could be forged (e.g. for voluntary or sheltered work) during the rehab process. The case manager should be someone with knowledge and experience of working with brain injury, and may come from a range of professional backgrounds. Personal qualities are key. He/she needs to take the lead in coordinating the work of the team and liaising with relevant services. This may include recruiting, supporting, and training carers; family intervention and support; researching activities and occupation; liaising with day centres, clinics, educational institutions, social work, families, etc. The team assembled for a given case may include a neuropsychologist, occupational therapist, physiotherapist, nurse, social worker, psychiatrist, rehab assistant, support worker, etc. The CMS team has grown over the years to encompass a variety of rehab-relevant professions and of course the admin team.
The progress that can be made through rehab is increasingly important in quantifying a personal injury claim. The aim of the law in such cases is summed up in the dictum of Lord Scarman (1980) that one should “as nearly as possible put the party who has suffered in the same position as he would have been if he had not sustained the wrong”. What that means for each individual will depend on the progress they can make. Some need 24/7 support to live in the community. Others continue or resume education and find work consistent with their strengths and weaknesses. Some even set up their own business. Until rehab has been tried, there is no way of knowing just how far each will progress and their exact needs for care/support/training/etc. In order to achieve the best possible outcomes and the most exact possible statement of any future needs, it is necessary for the legal and clinical practitioners to cooperate closely to achieve the best possible outcomes. The Rehab Code provides recognition of this – PI cases are no longer about the biggest award of damages possible but about the best outcome possible. Rehab funded through the medico-legal process has become a substantial part of the overall rehab available. In Scotland some 3-4 years ago case manager led rehab (from various organisations) amounted to about a third of all rehab being provided including NHS rehab[ii].
For the future, our goals in relation to brain injury case management include:
- Establishing further and clearer evidence of outcomes;
- Drawing on our database to show that community placements endure successfully when properly managed, even in challenging cases; and
- Developing the service in such a way that it becomes more widely available.
Dr Bill McKinlay,
Consultant Neuropsychologist and CMS founder
[i] Neil Brooks is now with Rehab Without Walls in Milton Keynes
[ii] Analysis carried out at CMS by Anna Weglarz & Bill McKinlay based on data from case management providers and the ABI-National Managed Clinical Network: 75 of the total 240 places were case manager led rehab in the community, a proportion that was rising.