Since the very beginning of Keystone Case Management, its senior team have been committed to delivering the highest possible standards, including through its written work and reporting. Here, Susanna Robinson, quality manager expert witness, discusses KCM’s focus on adopting a suitable clinical framework, and its role in enabling it to best support clients
Starting a clinical case management company, in what is rapidly becoming an increasingly busy marketplace, is no mean feat and full of interest. This is particularly so when pitching into the area of supporting clients, along with their families, who have experienced a catastrophic and utterly life-changing event with consequent injuries.
When Keystone Case Management (KCM) launched in late 2021, this followed many weeks of work by Niccola Irwin, managing director of KCM, and the senior team at Frenkel Topping Group, in creating the company structure within which to operate. Niccola’s work also included gathering a team, identifying a mission and values, discussing practice and potential, and meeting clients and commissioners. These were all some of the elements required to initiate a high quality, clinically-led company.
Aside from the business aspects a new company requires – such as the investment needed, the hardware and software items, the accounting, communication and client management systems, and an environment from which to operate – there is a need to clearly identify the clinical framework which will guide the delivery of frontline services.
In the context of case management work this is essential to align the approach and ‘thinking’ of clinicians within the company, many of whom come from different professional backgrounds. For managers, it can guide the choice or development of assessment and outcome measurement tools which reflect the values and ethos of the organisation and the current evidence base. The clinician, sometimes working for the first time as a case manager, can find a theoretical framework applied to all stages of the case management process – assessment, goal setting, intervention, evaluating outcome – provides clarity.
In short, an underpinning framework of practice provides the foundation from which all processes and tools can evolve with the overarching aim of providing a structure by which the needs and the progress of clients can be clearly communicated. The style and format used for these tools usually become recognisable as ‘templated’ to a company and intrinsically communicates to clients and customers what the company is ‘about’ or what it offers to differentiate it in the market.
Susanna Robinson
The formal written output of case management and expert witness work, for which services KCM was started, is the overt and potentially defining demonstration of where any framework, or template, is applied. Like it or not, such output will often form for the reader a first impression of the company and so it is essential that this communicates not only a response to any instructor’s request, but also the ethos and quality level by which the company wants to be known and build its reputation. An example of output includes the Immediate Needs Assessment Report which is written when assessing a client for the first time, or the initial report that the expert witness is commissioned to write.
In case management, the Initial Needs Assessment Report is also a means of assisting case managers to logically structure and assimilate the information they have gathered when assessing and prioritising any new client’s needs. It needs to be clear to the client (the injured person), the fee payer and all other stakeholders what the intention of the case management is, the expected benefits for the person, the level to which it is client-centred, what is the likely duration and what are the likely outcomes.
Whilst it could be perceived as relatively straightforward to develop a template to encompass this information, KCM’s team viewed this as an opportunity to adopt an evidence-based framework which would inform the development and structure of relevant templates for clinical practice (and shape communication) going forward.
The KCM senior management team are all healthcare professionals and as so are familiar with using theoretical models to inform the clinical practice and decision making required to deliver an excellent service to clients.
Their questions were – what does a high-quality Immediate Needs Assessment Report or initial Care and Occupational Therapy Evaluation (expert witness report) look like? What information is it crucial to include for the benefit of the injured person and the fee payer? What will help to gather information in a logical manner and communicate the findings clearly? What will subsequent reports look like to keep clients and fee-payers informed of progress in the case management process?
Using the World Health Organisation ICF
After due discussion and research, it was agreed to use the well-known framework provided by the World Health Organisation’s (WHO) International Classification of Functioning, Disability and Health (ICF) as the underpinning structure for KCM’s clinical work reporting (WHO ICF, 2001).
The ICF, as it is commonly referred to, is the WHO’s framework for measuring health and disability at an individual, as well as at a population, level. It was officially endorsed by member states on 22 May 2001 as the international standard to describe and measure health and disability. It is a classification of health and health-related domains that help to describe changes in body function and structure, what a person with a health condition can do in a standard environment (their level of capacity), as well as what they actually do in their usual environment (their level of performance). The domains are classified from body, individual and societal perspectives by means of two lists: a list of body functions and structure, and a list of domains of activity and participation. In ICF, the term functioning refers to all body functions, activities and participation, while disability is an umbrella term for impairments, activity limitations and participation restrictions. ICF also lists environmental factors that interact with all these components.
As clinicians, the KCM management team are well-used to the concept of an individual performing ‘occupations’ of daily life, in the context of a social or physical environment. Moreover, they are skilled in understanding the impact any underlying difficulty (impairment) a person might have in their body systems as a result of an accident or injury, has on their ability to ‘perform’ tasks effectively, independently and/or safely.
For clients who have catastrophic events, they often experience disruption or dysfunction within a wide range of body structures and systems, as well as on psychological and social aspects of their wellbeing. It is often a complex presentation of difficulties and how each person responds to their situation is unique. As therapists we know, for example, that two people experiencing a similar physical trauma can react and recover in potentially very different ways – one becoming fully independent and regaining their previously enjoyed life roles and another being permanently less able and requiring life-long assistance. As Lukersmith et al. (2016) point out, the ICF articulates the biopsychosocial model of health, this interaction of the person’s impairments of body functions and structures, their activity limitations and restrictions for participation.
By defining the domains of health including the influence of contextual factors on functioning, the concepts and language in the ICF align with the approach taken in what KCM seeks to do as a community based and person centred case management company (Lukersmith et al., 2016). Adopting this model aligned with KCM values and ethos but essentially, with careful training at induction, could help ensure that each individual client could be viewed and assessed as such by any clinician employed.
When interviewing the client and their family or caregivers to obtain information, the case manager is extracting information about all domains in a naturalistic, two-way conversation that builds rapport and demonstrates empathy – as much as possible. In our transposing of this information into a written report, the KCM assessment template provides the reader with contextual background related to the life-changing incident, and the environmental context, both social and physical, within which the person needs to perform their occupations. The reader is then given a factual account of the impact on body functions and structures and is presented with observed evidence of impairments to a client’s body systems. The following section of the report template focuses on the impact on a client’s activity and participation; that is, how the impairment translates into affecting their ability to do their daily living tasks and fulfil their life roles.
The intent is to build a picture of how the person lived their life pre-injury and how they are now living due to their changed circumstances. It includes the amount of assistance and care they may have had or continue to need for the near or long term future.
Using an outcome measure: the WHOQOL-BREF
An essential section to the KCM template and case manager’s interaction with the client, is to present the findings of an outcome measure. There is a dearth of measures which precisely and accurately measure the impact of case management intervention for a client as further described by Lowry et al (2022). This has been, and will be, the subject of other papers and is not intended to be discussed in full here.
Save to say that until (if) these measures become available, KCM want to ensure use of appropriate and suitably robust tools which capture aspects of the client’s progress. This should allow a more objective reporting on a case-by-case basis as well as provide data to improve case management services across KCM in time. The senior managers consider that it is important to actively investigate which outcome measures can be routinely used but, in the meantime, were of the view that it was appropriate to use the WHOQOL-BREF (1996), which is a standardised quality of life measure, again originating from the work of the WHO. Written permission to use this tool was gained from the WHO by KCM before incorporating it into the company’s documentation. Importantly, and essential to the KCM case management approach, this tool also allowed a clear opportunity for the client’s perception of their ’functioning’ (in ICF domains) to be documented.
The WHO defines quality of life as an “individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.” The WHOQOL-BREF is based on a four domain structure: physical health or wellbeing, psychological wellbeing, relationships / social wellbeing and environmental wellbeing. Adopting the WHOQOL-BREF was felt to compliment KCM’s use of the WHO to underpin the structural design of the Initial Needs Assessment report template. It was also important to the KCM team that the WHOQOL-BREF has been well tested for its measurement properties and has not been created with no consideration to its conceptual, mathematical or statistical robustness. Very importantly it was seen to have been used with a broad range of clients and was focused on trying to capture the client’s own perception of their quality of life, regardless of any judgments or observations of others.
In collaboration with the client, and in line with the client’s priorities, part of the case manager’s role is to suggest solutions to problems they may be experiencing. Presenting recommendations for helping to rehabilitate and restore the client to experience their pre-injury lifestyle as near as possible, is a key part of the report. By identifying a series of explicit goals which account for the client’s priorities and perspectives, as well as those of their significant others if appropriate, the case manager has the means to identify change and along with the results of the WHOQOL-BREF, indicate progress to the client, family and any other interested stakeholder.
As with all documentation used within the medical legal context, each report provides an opportunity for the case manager or expert witness to summarise their findings in a concise and succinct section and provide a considered clinical opinion on the client situation.
Designing a report template for the new company was, in the view of the KCM team, not simply a process of identifying key areas around which to ask the client questions. Instead, it presented an opportunity to review theoretical models and frameworks, and to identify a suitable, evidence-based framework to underpin and inform the clinical work and output of the company.
The WHO ICF has given KCM a relevant framework and structure from which we have been able to devise our documentation as well as deliver other aspects of our clinical service. Using this framework has enabled the development of KCM templates and clinical tools which reflect the values and ethos of the company but more importantly, clearly communicate the needs and progress of the client to all interested parties. By being clinically led and focused, and using tools grounded in clinical evidence, it enables the company to have a strong foundation from which to deliver a quality service where the client maintains centrality.
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References
Lowry J, Wakeham T, Norman A, et al (2022), Whose Outcome is it Anyway? Outcome and Brain Injury Case Management. Journal of Long-Term Care, (2022), pp. 114–129. DOI: https://doi.org/10.31389/ jltc.107
Lukersmith S, Fernandez A, Millington M, and Salvador-Carulla L. (2016) The brain injnury case management taxonomy (BICM-T); a classification of community-based case management interventions for a common language. Disability and Health Journal, (2016), 9, pp.272-280.
WHO ICF (2001) International Classification of Functioning, Disability, and Health: ICF. Geneva:World Health Organization. https://www.International Classification of Functioning, Disability and Health (ICF) (who.int)
WHO (1996) WHOQOL-BREF: Introduction, administration, scoring and generic version of the assessment. Field trial version. https://www.who.int/publications/i/item/WHOQOL-BREF
