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The multifactorial challenges of care provision for case managers and clients

Jackie Waggott, BABICM advanced case manager and director, Social Return Case Management, writes for NR Times



My role as a case manager includes supporting clients with rehabilitation, support and personal care needs. 

While some clients will benefit from a support package staffed by directly employed support workers, there are times when the best fit for the client will be to work with a suitable care or nursing agency to provide this support. Whether the client requires directly employed support workers or specialist agency care, establishing a successful, individualised care package has always been challenging proposition. 

More recently, the scale of this challenge has increased substantially. 

Across the UK there is awareness of the pressures on the care sector (both within public and private services), which have significantly increased over the last couple of years; only recently the British Association of Complex Case Management (BABICM) conducted this piece of research which highlights the challenges faced by users of care services, staff, commissioners, providers and coordinators/managers of care. 

In the context of the current challenges, there are a range of factors case managers consider when supporting their clients to choose their care package provider.

Often the first place to start is with funding. Is the care package going to be funded by the state? – via health, social care or joint funding. This means that the case manager has to be able to support the client to navigate through the health as social care funding assessment processes.

As a case manager, statutory funded care means that your ability to be closely involved in the choice of provider may be extremely limited to non-existent and is often dependent on the relationship you have with the local commissioner.

If a client is entitled to this source of funding then clearly it is the start point and should be considered. It is likely that the local authority or CCG will defer to their list of approved providers, and a match could be sourced via that route; but it doesn’t mean that alternative providers cannot be suggested. It may be that a specialist provider can be considered and added to the approved provider list or spot-purchased, but it may be that direct employment is the best way forward.

As a case manager, sharing information, assessment outcomes, knowledge and recommendations with the commissioner – in the context of knowing your client’s case in depth and as to advocate for your client’s needs – is an important part of the process.

It is not unusual to find that you have to start from the beginning; explaining the role of the case manager and then forging a working relationship with the commissioner before moving on to this. Unless they have encountered the role previously it can be confusing to understand the remit and role of the case manager and I often spend time mapping that out in the first meeting.

Our roles may differ, but we generally aim towards the same outcome so our duty is to ensure that we communicate in accessible terms and agree a partnership to get the best-suited care package possible withn the frameworks for that client.

Despite the potential benefits, it remains the case that personal budgets are not widely taken up – I would say that despite their launch some years ago there is little in the way of information and guidance for either the professionals looking to implement or access them, or for the client looking to take up the opportunity and their responsibility to manage and coordinate them. Direct employment via a personal budget gives the person more control, along with more responsibility and so it is not for everyone.

Employment issues and staff management is a specialist skill and our clients may not want to dip their toe into this at a time when they are seeking additional support to meet their needs. There is also the matter of whether the person has capacity to manage and consent to their own care, whether personal care is required, and whether funds are managed by a Court of Protection deputy, all of which bring different considerations to the fore regarding which routes are open for consideration. Often the most bespoke and specialist care packages I see are directly employed but by the very nature of my role, they also have a case manager in the mix, supporting where required.

With a case manager, the matter of managing a personal budget becomes less cumbersome and anxiety provoking for clients and there will be a level of evidence and governance embedded when the review date comes round.

Agency care packages are another widely used option and a criticism often advanced is that use of an agency is more expensive. I would argue that this depends entirely on the nature of the support package. If you consider an agency hourly rate (which includes recruitment, training, coordination, rota management, supervision, records management, payroll and holiday/emergency cover) this may in fact be cheaper than paying a case manager to manage these areas where a client is unable to do so themselves, particularly when the client requires only limited or sessional support.

Case managers are only able to direct and manage regulated care activity when they (or their organisation) hold CQC registration and currently not all providers have that governance in place, so therefore cannot legally establish regulated care without the use of a CQC registered agency.

More recently we have seen the emergence of ‘blended’ hourly rates being charged by care agencies which removes the issue of different hourly rates for weekends, evenings and bank holidays and provides one set rate which takes of this all into account. We are yet to see whether this has an impact on cost to the client but it certainly makes understanding costs of a care package more accessible. 

Alternative options include ‘care brokerage’ companies which provide a middle ground, helping clients to recruit and set up a care package with a view to taking them on direct employment once the package is established. It is great to see that choice and accessibility is widening but I also think that ‘necessity is the mother of invention’ and there has been a need for a broader range of options, of which this is one.

So funding and navigating the appropriate pathway to implement a care package is complex – and that is before we are out of the starting blocks. As a case manager not only do we need to consider the options, we must also support our clients and their representatives to access them and be clear in the rationale for each route and any choices and decisions at every step of the way. 

Some of the reasons that may influence the rationale of the case manager are obvious, others are less so. Care needs and complexity are a huge factor and this is where a comprehensive, holistic assessment is vital. A clinically very complex care package requiring specific expertise may be best met by a specialist agency to provide a range of nursing, behavioural or other skills which might be challenging to attract to a direct payment funded package. Similarly using an agency would be indicated if one were to be expecting a high turnover of staff due to the nature of the package or the client’s circumstances; the agency option can potentially minimise the burden of cost of recruitment and training which would be borne by the agency, who are best placed to do this more cost effectively across a service where they can re-deploy staff.

The logistics of a care package may influence the choice. Are carers located close by to the client? How many visits per day are required? Are ‘live in’ staff required? Are a specific set of support worker characteristics necessary for the client? For example if a client requires specifically either male or female support, availability is reduced by roughly 50 per cent (and likely more if the need is for male support). Then if they need a driver the percentage reduces further. Then if they have English as a second language and require a speaker of their first language then the percentage drops even further. This may sound extreme but it is something I have come across on cases. 

What if the client that has recently sought case management support is receiving palliative care? In these circumstances agency workers can be a choice which better protects the client should there be unplanned events and sickness impacting on care shifts and may potentially protect the worker from sudden unemployment in the event of the client’s death.

On the flip side however, directly employed staff could be seen as being more able to provide consistent and personalised care under these circumstances and at a critical time at the end of someone’s life. As all the parts of the decision making come together it is clear that this can present complexity when individual needs are considered in depth.

All of the above was a challenge before Brexit and before the pandemic and now we and our clients face additional difficulties. Care staff are tired and rates for care have risen. Care staff are tired with the work they have relentlessly done through the pandemic, tired with poor pay and conditions, tired of being viewed as unskilled workers with low regard for their skills and expertise. Hourly rates have more recently risen to reflect the value of care provision and also to reflect the scarcity of resources and the need to promote retention in the industry, but this presents a challenge for funding and represents a mismatch between capacity and demand. 

So what does that all mean in practice? Some thoughts:

  • There is no substitute for a clear and comprehensive assessment of needs as a starting point to building the right care package and case managers are well placed to work with the client and provider to make sure this is possible.  
  • Care providers who provide good quality records, which outline needs, interventions and impacts are incredibly useful for the case manager (and if the case is in litigation, also the legal team). This means that concerns and queries can be addressed quickly and evidence of care needs are available to paint the picture of recovery and future need for when the legal case is approaching settlement. 
  • It is helpful to know the client’s CCG and their local care providers – having an understanding of the frameworks and local nuances as well as proactive working relationships with key people can help with communication and therefore meeting the joint goals we are all working to achieve.
  • The cost of care is rising and sustainability of care packages in the community are being challenged but with the right set up, the right terms and conditions and the right match of client to support workers this can be avoided or at least minimised. It is also important here to note the thought – what indeed is the cost of poor quality, or no care?
  • Excellent care cannot be bought cheaply and neither should it be; costs should reflect the quality expertise and importance of the role. We need to be able to access adequate funding for our clients via whatever route – however that’s another blog, for another day!

Finally, collecting and sharing views and experiences of professionals and those they support in forums and surveys such as the BABICM ’Perfect Storm’ and the government’s call for evidence on acquired brain injury helps inform both the local and national position, which one can only hope will assist in moving forward, closer to a position of being able to source well-resourced and excellent quality of care with fewer challenges on the road to achieve this.