If case managers diversified into producing cars, they would be hand crafted in the hue of client choice. This is because of the widely accepted guiding principle that we as rehabilitation professionals and case managers are client centred in our work.
Working in the medico-legal setting can be a key factor in enabling the case manager to be client centred. I recall how excited I was by the scope of the role as a new brain injury case manager.
The opportunity to be effective, creative and flexible in client work was a welcome change from the restraints of statutory eligibility criteria and limited service provision that characterised my previous role.
However, 17 years later, it is interesting to consider the potential challenges and conflicts for the client centred case manager when working with brain injured clients in this context.
The principle of personal injury law is to return an injured party, in so far as possible, to the position they would have been in, but for the injury. To that end, brain injury case managers are often instructed by the claimant’s lawyer to set up and manage a support package, or co-ordinate an interdisciplinary rehabilitation team.
Our instructions and role vary, but our clients are often significantly cognitively impaired, have various neurobehavioral difficulties and may have some neurophysical impairments.
In the medico-legal context, it is very helpfully established that the practitioner case manager’s duty is to the client. This was set out in a Court of Appeal ruling (Wright V Sullivan, 2005), with Lord Justice Brooke stating that the relationship between the case manager and the claimant had to be therapeutic.
Also, the case manager should owe his duties to the patient alone. He must win the patient’s trust and, if possible, his co-operation.
While it may be in the patient’s interest that he should receive a flow of suggestions from any other experts who had been instructed in the case, the case manager must ultimately make decisions in the best interests of the patient and not be beholden to different masters.
Clearly our duty, therefore, is to be client centred. In practice, however, even the most dutifully client centred case managers can face various conflicts and pressures.
Conflict one: Timescales
The first principles of case management are to establish and maintain a positive working relationship with your client. Some clients and their families may throw the door open, delighted to have someone to help them get their show back on the road.
However, you may find that with other clients, getting past the front door is a major achievement in itself. Your client may have reduced insight into their injury and limited motivation to explore sources of support or rehabilitation.
They may have neuropsychological or psychiatric issues that present barriers to engagement. They may have a very limited ability to understand the purpose of litigation or accept the need for a case manager.
On occasions such as these, the case manager is required to put all other issues to one side and go back to the basics of finding some common ground to engage the client.
I have used various methods for this, taking cues from anything in the house, from talking about football, taking dogs for walks or in-depth discussions on the merits of various albums.
If you can engage the client in discussion, you can work on developing rapport. Rapport enables you to listen to what’s going on in their life, what’s important to them and what is it that they would like to change or achieve.
This process can take a long time to get to a place where your client trusts that you ‘get them’ and are really listening to what life is like for them, without judgement.
Once you have established that you are working in partnership, only then can you begin the process of trying to move forward to where they want to be.
The establishment of a trusting partnership is a vital part of the client centred approach.
All of which is fine, as long as you have an experienced, patient-instructing lawyer that understands the nature of working with your brain injured client and is prepared to accept your identified timescales.
Lawyers fight hard to gain interim payments to fund case management, care and rehabilitation.
Getting these frameworks in place in a timely manner and collecting the evidence to demonstrate an established need for the purposes of the case, may be their priorities according to their case strategy.
Some case managers may find themselves working with lawyers (either on the claimant or defendant side) who don’t fully understand the client’s brain injury and barriers to engagement.
There may be pressure for speedy outcomes and the case manager may feel required to progress apace.
The case manager here faces a conflict and the only client centred solution is to stand firm and explain the rationale. In order to ultimately achieve anything, the case manager has to persevere with the challenging process of building up a trusting partnership at the client’s pace, and not at the lawyer’s.
Although I refer here to the initial process of building up the relationship, the same principle applies to maintaining it.
You establish your working relationship at your client’s pace, and then you maintain it by moving two steps forward, one back, (or even sideways) then forward again, with the case manager gently pushing the dynamic to achieve jointly agreed goals.
Good documentation is crucial in evidencing the input hours involved in supporting clients to achieve their goals and will ultimately be very helpful to the experts. It must also be said that it is essential for the brain injury case manager to have suitable skills and experience to facilitate and maintain engagement.
Another timescale issue is that of medico-legal expert assessments. Timescales for expert reports are determined by the courts, and the constraints of busy experts’ diaries, rather than clients.
This can be a problem for clients who are trying to engage in a structured programme of support/rehabilitation that periodically is interrupted to accommodate lengthy expert assessments, sometimes at home, sometimes at clinics in different parts of the country.
Visits often appear to occur in phases when several assessments happen in a relatively short time.
Clients may not always understand the relevance of the assessment and require persuasion to attend, with the case manager often asked to accompany them.
The appointments themselves can be illuminating for clients and their families, but on occasion can also be very distressing and trigger unhelpful changes in behaviour or negatively impact fatigue and engagement.
This necessary part of the process of litigation should be dealt with as sensitively and practically as possible, and often requires significant support from the case manager.
Client centred case managers must advocate firmly for their client, be the voice of reason and consistently seek to work with lawyers to make expert assessment schedules as painless and non-disruptive as possible for the client.
Conflict two: Goals and opinions
In terms of defining goals, everyone has an opinion. The client may feel strongly about what support they do or don’t require, what activity will benefit them and what they actually want to achieve.
There are also opinions expressed by the family and everyone else involved in their care or rehabilitation. Finally, there is the medico-legal expert opinion.
On Case Manager Cloud Nine, all opinions of what the client needs happily coincide with that which they identify themselves.
However, back on Earth, reality dictates that more often than not, opinions are divided. The expert is a key person in litigation and their opinion evidence is essential in the acquisition of interim funds and eventual damages.
Experts make recommendations about the client’s long term needs for the purposes of putting together a schedule of damages, ultimately for the court’s consideration.
Their support of the existing input at the time of assessment is important to the case and ongoing funding. There is therefore some pressure on the case manager to implement services along the line of their recommendations.
However, what the experts recommend may be quite some distance from what the client actually wants to do.
Often the case manager also believes the course of action recommended by the expert would be beneficial to the client, and may have been trying to engage the client in exploring this option for some time.
Capacity issues are outside the scope of this article but addressing client capacity and best interests is very relevant to the ongoing work of the case manager.
Common scenarios are where a medical expert reports that the client requires intervention, such as residential rehabilitation, which is rejected outright by the client, or a care expert recommends a level of support that is more than the client is prepared to accept or can tolerate at that time.
Another difficulty can occur when the expert opinion sets out the timescales in which they expect to see specific outcomes, which may not always coincide with the timescale the client is working to.
The case manager may feel conflicted when faced with expert expectations and recommendations which are rejected by the client; a dilemma for the case manager who is trying to keep the client at the centre of their practice.
The case manager may agree with the expert opinion but are unable to progress it because the client rejects it. They know that support from the expert is important to their ongoing input and possibly their continued funding.
They may also be painfully aware of court cases where case managers have publicly come under criticism for not following the recommendations of experts.
In working with the client on these issues, the case manager has to manage client engagement, welfare, capacity, risk issues and family needs in negotiating a realistic way forward that is acceptable to the client and in their best interests.
The way forward frequently starts off looking like one path, changes over time, and is not always as mapped out by the expert.
Experienced case managers understand the medico-legal context and also the function of the expert, whose duty is to the court. The case manager may also find it reassuring to remember that the opinions of experts are often hotly contested by opposing experts on the same case.
Fundamentally, the case manager deals with this pressure by remembering that their own duty is to the client.
When an expert or treating professional recommends a course of action that the client is unwilling to engage in, the case manager should present options to the client, explore and encourage potential ways forward, and address capacity and risk issues.
Their role is to try to enable (via rehabilitation or support) the client to pursue their goals as far as is possible within the boundaries of funds, safeguarding and the law. The golden rule is to document what you have done, including barriers to pursuing various recommended options, and the expert can review the evidence available to them.
Conflict three: Evidence and relationships
As discussed, a positive relationship between the client and the case manager is essential for client centred practice.
However, a further challenge created by the medico-legal setting is the disclosure of evidence whereby case management records are open to scrutiny by legal teams and experts, and potentially the client or their litigation friend (often a family member).
Although intrinsic to the medico-legal process, it can cause difficulties for the case manager. Case management documentation often includes analysis of potentially contentious issues, and may refer to difficult family dynamics or other sensitive issues that are relevant to intervention.
Disclosure of this information can affect the quality of the relationship between case manager and client or their family. You may feel conflicted by the knowledge that revealing tricky issues may have a substantial impact on your relationship and be faced with the dilemma of what to record.
Another issue caused by disclosure is that the client who is cognisant of the fact that notes are disclosed may choose not to share issues with you, which may also hinder a meaningful relationship. It is relevant to note that your role is ‘Witness of Fact’.
It’s helpful for the court and experts to know the situation on the ground, however difficult for the client or family to read, in order to make accurate assessments and recommendations to meet long term needs.
It’s essential to work closely with the lawyer to address this issue and deal with disclosed information as sensitively as possible, and with reference to the client’s best interests. Case managers need to be prepared for this situation, and how to deal with it through supervision.
Many lawyers offer excellent training on recording and disclosure of evidence. In summary, although the medico-legal context provides the opportunity to work in a client centred way, case managers also have various issues to navigate in order to remain truly client centred.
It is important that we hold on to the fact that our duty is to the client, if faced with conflicts or challenges, and seek supervision in dealing with them.