A case study by Lucy O’Connor, Unite Professionals
From a Neurorehabilitation background in the NHS, I am experienced in working with clients following a Traumatic Brain Injury, new into the world of Case Management the first client on my caseload had sustained a TBI and was an inpatient at a major trauma centre in the South of England.
I first met my client, a 20-year-old male, and his family in March 2024, 3 months after his accident, whilst in hospital, I will refer to him as Josh throughout!
At this stage Josh was on a Neuro Ward receiving inpatient MDT rehabilitation, therefore Case Management input was limited.
I liaised with the treating team, explained my role and what potential input I could have to facilitate and support Josh’s recovery.
Although it was important that the treating MDT was aware of my role, I remained respectful of their roles and time pressures, exercising caution not to add to their workload.
Prior to discharge home Josh was assessed and accepted to attend an outpatient cognitive rehabilitation service, on discharge.
I was not involved in the assessment; however, I had knowledge of the team and the structure of the service, ensuring that I had contact details of who Josh’s Key Worker would be, along with their working days.
In-reach Case Management whilst client continued to access NHS rehabilitation included:
- Organising a taxi account enabling Josh to travel to rehabilitation services for daily therapy, the distance from Josh’s home and being dependent on others for travel was a presenting barrier to him engaging in rehabilitation.
- Liaising with the outpatient cognitive rehabilitation service team explaining the CM role and how Case Management could support.
- Regular discussions with the MDT and Josh, including attending MDT meetings. Risk management, following a Safeguarding concern being raised during Josh’s inpatient admission
- Support for engagement was initiated, following concerns raised by Josh, family members and the MDT regarding potential risks of disengagement.
Following the assessment, Josh declined ongoing intervention under the rehabilitation services in April 2024 after assessment, engagement efforts continued in light of the identified risks.
Review of the outpatient cognitive rehabilitation service discharge report documenting higher level cognitive impairments such as reduced processing skills, planning and attention, the recommendations allowed Case Management to proceed with private rehabilitation under the rehab code.
Impairments of awareness and insight may affect a patient’s ability to engage in rehabilitation in the immediate period following ABI, but this may change.” (Rehabilitation following acquired brain injury, National Clinical Guideline, p18)
An INA visit was completed promptly at the Josh’s home at the end of April 2024. Goal areas established with Josh included:
- returning to meaningful employment
- talking therapies
- obtaining a UK car driving licence
- returning to previously enjoyed hobbies / interests
Presenting barriers at the time of the INA included:
- Josh did not believe that he had any residual impairments following the TBI Josh’s mobility had improved significantly, therefore he believed that he was back to his pre-admission baseline
- Josh presented with hospital and therapy fatigue
- Limitations of patients’ insight and awareness of their difficulties in particular, may impact on their ability to engage effectively in rehabilitation, and may therefore affect the timing of intervention (Rehabilitation following acquired brain injury, National Clinical Guideline, p18)
Positive attributes for rehabilitation at INA included:
- Josh was keen to engage in psychology input to talk about what he had been through
- Josh agreed to an Occupational Therapy and Physiotherapy assessment to obtain support with returning to meaningful employment and to further improve his mobility,
- Josh was receptive to CM input, taking CM calls and he would call the CM to discuss any issues or concerns that he was experiencing
- Josh was eager to resume his previous activities, return to employment and ‘normality’
- “The cognitive effects of brain injury may not be as obvious in the early days of injury and may be more apparent once the brain injury survivor has returned home or attempted a return to work. They may therefore take longer to understand and adjust to than some of the other effects of brain injury.” Headway
Rehabilitation:
- Weekly Neuropsychology input, focused on establishing a valued therapeutic relationship
- Specialist Neuro-Occupational Therapist completed initial assessment and 1 session, this input was terminated by Josh when he found temporary work believing that this was the sole purpose for the OT input
- Specialist Neuro-physiotherapist provided exercises and intermittent review of Josh’s progress, scheduling these sessions around his work became challenging
- Josh was deemed medically fit to drive by his GP, consultant and DVLA, passing his car driving test and obtaining his UK car licence
- Reviewed by the NHS Consultant Neuropsychiatrist who discharged Josh from their care
- Commenced employment at Kwik Fit
Discussion with Clinical Lead:
- Josh had made good progress returning to work and some meaningful activities
- Josh continued to communicate regularly with the CM, however, he was reluctant for any further rehabilitation intervention to continue other than psychology
- Potentially discharging the client
- “In some cases, it may be appropriate to keep the patient under review and defer intervention until s/he is ready to engage.” (Rehabilitation following acquired brain injury, National Clinical Guidelines P43)
Discussion with Josh February 2025:
- During a telephone call with the CM Josh reported an episode in work when working a different shift, reporting to a different manager
- Josh described that he had been given multiple verbal instructions, and he was unable to process, retain or prioritise the information / tasks appropriately.
- This lived experience allowed Josh to reflect on his recovery to date and how this could impact his future
- Rehabilitation after traumatic injury, NICE guidelines 2022 recommend guided self managed rehabilitation to allow the person to engage in rehabilitation in their own time and by their own schedule.
Actions / events following lived experience at work:
- Continued discussion between CM, Neuropsychologist and physiotherapist
- Neuropsychology recommended ADHD assessment and Neuropsychiatry assessment
- Neuropsychiatrist recommended medication which Josh started taking, reporting a positive change in his thinking, mood and impulsivity
- The Neuropsychiatrist and Neuropsychologist have completed joint sessions to plan ongoing intervention
- Recent visit by CM to Josh established that he continues to have difficulty with some elements of processing and multi-tasking.
- Josh has agreed to an Occupational Therapy assessment to assess this further to develop his understanding of how it could affect his daily life and potential strategies to manage this
- Through education and discussion, Josh has gained further understanding of the brain and the recovery process
- Josh is employed at a golf club and has taken up golf
- Josh has enrolled onto a plumbing and heating course at college
The Importance of time in recovery:
To allow the client to:
- develop a trusting, working relationship with the Case Manager and Psychologist where he felt safe to confide
- adjust to their situation, identifying what is important to them
- participate in rehabilitation at their own pace, at an appropriate time for them take a lead in their therapy and focus their goals on what is meaningful and important to them.
- Rehabilitation after traumatic injury NICE Guidelines 2022 recommend a tailored and personalised journey towards the person’s agreed goals, focusing on what is important to them, developed with the person
To allow the CM to:
- understand how important lived / real-life experiences are in rehabilitation, and to portray this to referring parties
- recognise the importance of reflection on events for the client, CM and MDT
Conclusion
The therapy and adjustment process for clients is fluid and the trajectory for recovery post-TBI is unique to each case.
It is okay to recognise that therapy has plateaued, slowed down, needs to be paused or reimplemented at a time that is best for the client.
There is value in giving post-TBI clients time to adjust and learn through experience.
Find out more about Unite Professionals at uniteprofessionals.co.uk
