The role of the case manager in the continuum of care

The case manager can receive a case at any phase in this continuum of care and recovery. Depending on the stage at which the case is received, different work may be needed. In some cases, when a case is received at a later stage in the continuum, the case manager may work with the physicians to determine if all necessary care and treatment were given to the patient. If it is determined that additional care was needed in an earlier stage, the injured person may need to go back for further care. This continuum of care is a general guide and the case manager will work to explain the guide to the insurance company to ensure that reserves are adjusted, if necessary, during the rehabilitation course.

Hospital (ER, ICU, acute care)

The initial referral to the case manager will include instructions to obtain the medical records, cause of injury, surgical information, and plan of care from the treating physician. Generally, the first task is to meet with the Utilization Review personnel at the hospital to obtain permission and information and to meet with the patient and family. In catastrophic cases, a trauma care coordinator acts as the hospital liaison with the case manager. The case manager explains his or her role in facilitating any necessary communication between the hospital and the insurance company. The case manager’s involvement is a mutually beneficial and cooperative because both parties need the assistance of the other in management of the case. The case manager meets with the patient to determine his or her status and to put the medical records into context. A visual meeting can tell him or her a lot about the status of the patient and puts the medical records into context when they are reviewed. The case manager also meets with the family to see how they are coping with the injury and explains his or her role in assisting with the care of their family member to evaluate the services needed and the options available to meet the injured person’s recovery needs. The case manager aims to build a rapport with the family and to elicit cooperation by explaining that he or she will be working with the family through the continuum of the recovery for the long-term. In cases where the claimant has suffered a work related injury, the case manager explains that the long-term goal is to facilitate their loved one to the point of recovery where he or she will be able to return to work. During this time in the care continuum it is important to remember that the family has just been through a traumatic event and emotions are running high. Attempt to keep the family focused on the positive and give them an end recovery goal to work toward.

In most cases, when the patient emerges from coma, is able to respond to localized external stimuli (Rancho level 3) , and is medically stable, he or she is transferred to acute hospital care for a short period of time and then to inpatient rehabilitation. At the acute hospital phase, the case manager will encourage and assist the family in visiting the in-patient rehabilitation unit (units which specialize in treatment for TBI). The case manager helps prepare the family in advance so that they know what to expect when visiting the patient. As a person with TBI starts to “wake up,” he or she can become agitated and may become physically and verbally aggressive. This stage is referred to as Rancho Level 4-5 . If the family is not prepared for this type of behavior it can be very disturbing. The case manager will explain that this behavior proves the patient is moving up the recovery scale and that the reason for agitation and aggressive behavior is due to the patient’s confusion and hypersensitivity to sound, light and touch. The Brain injury unit staff will manage these behaviors while keeping the patient safe by providing specialized treatment, controlled stimulation, a controlled environment and specialty equipment. The medical staff, along with the case manager, will educate the family about the brain injury and explain the patient’s needs so that when the family visits they will have an understanding of what the TBI unit provides. The case manager will help to put this information into context for the family and discuss future steps in the care continuum process. The case manager also updates the insurance company on the stages of progress across the care continuum. The case manager explains progress and the steps necessary for the patient to achieve a functional and productive life to ensure adjustments are made to the patient’s reserves as necessary. The end goal is always to assist the patient in recovery so that he or she may return to a productive lifestyle and in workers’ compensation cases in particular, to return the patient to the same job with the same employer.

Sub-acute facilities

Sub-acute facilities may exist as a unit in an acute care or rehabilitation hospital or in a nursing home. Patients are admitted to this type of facility if they are unable to sustain at least 3 hours of therapy per day. As their medical status improves, they are transferred to an inpatient rehabilitation hospital. The case manager will obtain updated information at least once a week at this level of care or more frequently depending on the patient’s medical status.

Rehabilitation hospital (inpatient)

At this level in the continuum of care, the injured person is physically able to participate in at least 3 hours of therapy—physical, occupational, and speech/cognitive/communicative/dysphagia (swallowing) therapy. A neuropsychologic evaluation is performed when the patient has sustained attention and concentration and can participate in a meaningful manner. If the patient is physically unable to participate for 3 hours a day, then he or she will be admitted to a subacute rehabilitation facility where the therapy demands are less. As the patient becomes stronger and more responsive, he or she can transfer to an inpatient rehabilitation unit. The case manager attends patient care conferences, usually on a weekly basis, with the rehabilitation team, obtaining medical and rehabilitation status and a time frame for discharge. The discharge location is important because the rehabilitation team needs to set goals with the patient (as possible) and his or her family. If the patient is to be discharged home, the family will need to be closely involved in the rehabilitation, participate in family teaching by the different therapists, and be able to understand the need for 24-hour supervision if necessary. Financial resources play an important role in determining the discharge site. The discharge planner in the hospital will assist the family in obtaining state and federal medical assistance if necessary. The discharge site may change again depending on the finances available.

Home health care

When the patient is able to be discharged to home, or in some cases, refuses to go to an inpatient facility and insists on returning home, home health services are often a good alternative. Home health services are often covered in medical insurance policies and many have specialized traumatic brain injury programs with therapists who can treat the injured person at home. A home based program can be an advantage in that the injured person is in a familiar setting and the rehabiliation is done in a functional, real-life environment. The case manager communicates separately with all therapists and the home health nurse because there is no team structure in a home based program. However, in a specialized program, the case manager coordinates team conferences where all team members are in communication with each other.

Community re-entry program (residential and outpatient day program)

Community re-entry programs are staffed by trans-disciplinary TBI rehabilitation teams which address the deficits in individual and group environments at home and in the community. The case manager attends regularly scheduled team conferences, usually on a monthly basis, with the rehabilitation team, including the injured person and his or her family members. Rehabilitation usually lasts for several months; vocational rehabilitation, if appropriate, is integrated into the program as early as possible. The case manager facilitates communication between the vocational specialist and the employer, incorporating the patient’s job description into the total rehabilitation program. During the community re-entry level of rehabilitation, the patient may feel frustration in dealing with the challenging rehabilitation. The case manager works with the patient to increase the complexity and duration of the rehabilitation as time goes on in order to approach the level of function the patient was able to perform pre-morbidly. During this time, the case manager attends all follow-up physicians’ appointments and communicates the patient’s rehabilitation status to the medical professionals and to the insurance company.

TBI patients may also see a neurodevelopmental or behavioral optometrist to correct visual-perceptual and balance deficits through the use of specialized prism lenses and exercises. An evaluation by a neurodevelopmental and/or behavioral optometrist helps direct the physical and occupational therapists to assist the patient in performing specific and detailed exercises resulting in more functional outcomes than typical therapy alone. Prescription lenses also help to eliminate the visual-perceptual deficits without physical or occupational therapy intervention at all, depending on the individual patient.

Skilled nursing facility

In some cases, even after acute rehabilitation is complete, the patient may remain at a low functional level and not be able to return home. In this scenario the patient is admitted to a skilled nursing facility for long-term care. Lack of medical insurance for a specialized TBI rehabilitation facility can also cause the patient to be admitted to a nursing facility, especially if the patient is on public aid.

Long-term care

Patients who are unable to live at home, for a variety of reasons, may go to a specialized long-term care facility with a TBI in-patient residential program. These patients usually need 24-hour supervision and have significant memory, judgment, and behavioral problems that make it impossible for family members to care for them. In most cases a long-term care facility is the last resort after unsuccessful home trial visits. The patient’s safety and the safety of the family is a main consideration in making this decision.

TBI education for all involved: critical for optimal outcomes

In the initial stages, education of the family is the first step to helping them understand and deal with their loved one’s injury. The family will ask for explanations from several parties – the physicians, nursing staff, social workers, etc. Redundancy is good in this situation because absorption of information is difficult for people who are living through a traumatic situation. Case managers need to be sensitive to “information overload” during this trying time and provide the family with just enough information.

Education of the insurance provider is also important. It is imperative for the case manager to provide the insurance company with an understanding of the complexity of the injury, the time frames for recovery of the multiple injuries, the necessary rehabilitation, and the continuum of care. The case manager needs to lay out all the possible types of programs, services, equipment and personnel needs so the insurance company provides appropriate financial reserves for the care of the patient. An experienced case manager with thorough knowledge of TBI acts as a resource for the insurance company and an advocate for the patient. The case manager discusses the myriad of problems associated with TBI and the critical services needed to facilitate the patient’s recovery with the insurance company.

Case managers have a variety of resources available to help them increase their knowledge of TBI. Books, articles, conferences, on-line resources, attending brain injury support group meetings, the Brain Injury Association of America and state brain injury associations are all helpful resources. There is also a voluntary national certification program for experienced professionals in brain injury services is offered by The American Academy for the Certification of Brain Injury Specialists (AACBIS) .

Rehabilitation services to the underinsured

In most cases the hospital discharge planner will know of local facilities and funding requirements. Patients with no insurance attend programs funded by public aid. Each state has its own services available to patients with TBI. An excellent resource is the state brain injury association, which provides information on available services for rehabilitation. Some states also have vocational rehabilitation programs. There are also local TBI support groups are associated with each state brain injury association. TBI survivors, their family and friends, and other professionals are invited to attend. These groups are a community resource for networking, education, and support.

Geographic disparities in resources and quality of services

Major metropolitan areas typically have a wide range of services needed for a person with TBI and associated injuries. University medical centers outside of large cities would also have sufficient services. Rural areas, however, may not have trauma services and neurosurgeons . The services available to patients with TBI vary widely from state to state. The Brain Injury Association of America’s National Directory of Brain Injury Rehabilitation Services lists all services available by state .

Planning therapy with limited financial reimbursement resources

An example is a patient who had eight visits of outpatient rehabilitation therapy available from her insurance policy but was not ready for the physical level necessary for her to be able to participate and benefit from the services. It was suggested that she have home care services (included in her insurance plan) when she was discharged from the hospital. She had those services for 3 months and called at the end of that time to say she was ready to come to the outpatient program. An initial evaluation was completed in one session, and they were able to prioritize her deficit areas still needing compensatory strategies and work during the remaining sessions teaching those strategies. The patient also wanted to return to work and we referred her to the state vocational rehabilitation agency which was able to provide assistance in that area.