As she approaches her early retirement, Deborah Hale, clinical support manager at Westcountry Case Management, reflects on her move into case management, what she has learnt, and why she would recommend the career path to other health professionals
I started life as a case manager fairly late on and some 30+ years post qualification as an occupational therapist. Up until this point I had worked in statutory services progressing to senior management level, but still holding an active case load and working as a consultant on complex cases. I spent large portions of time providing leadership and management to a big team of professionally qualified OTs and social workers plus other trained assistants who provided the mainstay of our work.
I participated and led several health and social care initiatives and was a decision maker with an adult social care hat on at the CCG for CHC consideration. I dealt with dozens of complaints per week and became adept at “doing more with less budget” and supporting my staff to do a “good enough job” rather than providing gold standard interventions. That takes some getting used to and can be soul destroying if one lets it.
When I was suddenly and somewhat abruptly made redundant along with my entire peer management colleagues, I made my way into case management. I had considered this direction many times and always found a reason not to; risk of being self-employed, poor opportunities for CPD, lack of professional recognition, the concept of ambulance-chasing, lack of legal knowledge…. and the list went on.
My observations and the reality, however, could not be further from the truth and I wish I had found case management – and it had found me – at an earlier stage in my professional career.
It has given me the most wonderful experiences and provided me with meaningful, long-lasting and enriching client and family involvements and perspectives. I have learnt so much about the power and value of a trusted case manager to a client who often meets one at what could be at the lowest and darkest moments of their lives.
In statutory and health services, I feel confident in saying that all therapists and practitioners would purport to work in person-centred ways; non-discriminatory and non-judgemental, placing the patient or service-user at the forefront of decision making, involving people in discussion and goal-setting, obtaining buy-in from families and thinking creatively to maximise solutions.
However, this is almost entirely at the mercy of time constraints and targets; criteria-led and subject to rigorous gatekeeping. In these scenarios, practitioners and therapists are walking a fine line – the emphasis is on seeking person-led solutions rather than provision-led services, but with no capacity to find these. The thrust seems to be on using a strengths-based analysis rather than really honing in on what matters to people. The principles behind the legislative guidelines within which we worked have sound and meaningful philosophies and standards, but all too often workers are caught between those powerful intentions and the rigorous application and interpretation meted out by those in charge.
Apart from all the learning I had to assimilate on arrival to the world of case management, I soon understood that I now had the luxury of time; I had the chance to really get to know my clients and explore their aspirations and hopes. This occurred and was allowed to develop over the course of months and years.
Working in a relatively autonomous way has allowed me to better understand the pressures clients and their families are under. My knowledge and understanding of the world of statutory services has certainly assisted me and my fellow case managers in maximising the use of relevant and appropriate statutory support but also in knowing when to back down in order to bypass waiting lists and exhaustive, sometimes meaningless criteria.
Ask any case manager about a case study, they will tell you of an exciting venture they have been involved in which would never happen in statutory services; there are many examples of positive risk-taking, holidays and festival-going, winter sports and ocean cruises… all made possible by the tenacity and doggedness of the case manager standing shoulder to shoulder with the client.
The same case manager will not only conduct research and utilise evidence-based practice, risk assess, communicate and collaborate robustly, but will ensure that all legislative frameworks have been adhered to and consulted with the legal teams, deputies and families alike. Best interest decisions, CQC consideration, safeguarding measures and risk assessments will be undertaken and above all, the client kept at the forefront of decision-making and aspiration.
Being this closely involved with a client enables one to have some very honest discussions – some not easy at all, but the case manager becomes a critical friend to that person; someone who is trusted to challenge and be curious, to be a real advocate. It is that advocacy that has buoyed me up over many a difficult encounter with either solicitors, insurers or deputies.
The case manager is in that enviable position of being at the coal-face of a situation; supporting clients through difficult times and really hearing what is live to them. Many of our brain-injured clients live in the moment; skills such as rationalising, adjusting, envisaging, working out and calculating are sometime very confusing and agitating for them – the case manager is there as a steady hand on the tiller – to provide reassurance and clear messaging, delivered in an appropriate way that makes sense to them and their families.
Working with legal teams has also been hugely rewarding, not only getting used to being regarded as a highly skilled professional with a wealth of knowledge about their client, but also feeling really valued – a sense that some therapists rarely get to experience.
In the early days of an unsettled case, it became very apparent to me that a client is expected to undergo numerous and rigorous assessments and clinical testing as part of the legitimisation of their legal case. All the professionals involved understand the critical importance of attending these appointments willingly and wholesaled in mind, body and spirit.
For a client, however, this is a massive expectation, particularly for those with a brain injury. It can also prove quite a negative experience – emphasis in the main on retelling the story that has devastated your life and focussing almost exclusively on the impact of that incident – a discussion about all the things you can no longer do. The appointments can be miles away from familiar locations, they may require the use of public transport and the consultations can take hours or sometimes just a cursory 20 minutes – both carry equal amounts of stress and uncertainty about them.
I have keenly felt the need to “walk in the shoes” of those clients and their long-suffering families and to employ practice-based evidence to advocate on their behalf.
With settled cases I have enjoyed “walking alongside” clients in different circumstances. There are always opportunities to look at things with a fresh perspective and challenge your client to consider the wider world and their interaction in it. Complacency in families and support teams is the watch-word for the case manager – ditto in statutory services, so employing a professional curiosity to those sometimes, entrenched positions, is critical.
The concept of outcomes and aspirations become central to that process – supporting clients to take positive risks and go after their dreams. Challenging teams, families and statutory services is also an incredibly important yet difficult process which will almost always involve the utilisation of sensitivity and diplomacy; using a coaching approach to support the re-framing of a situation has also reaped huge rewards and successes for me personally in these examples.
Case managers have to retain, commit and continue to develop their skills and knowledge across the private and public sector in order to remain credible witnesses and advocates for their clients. At Westcountry Case Management, I have enjoyed regular opportunities to share and develop my own knowledge and it is this commitment to ongoing development and training that has been so important to me and my fellow colleagues.
So, as I bid farewell to the world of case management and approach my early retirement, I would encourage any health professional to consider a career in case management. This rewarding, enriching and inspiring job role really will open your eyes to the genuine definition of person-centredness; embracing and demonstrating solution-focussed outcomes and evidence-based practice.
Case management can be the catalyst for that fresh perspective, so don’t delay!
