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12 September 2008:
Don’t shoot the Case Manager…….
BICMA, the Bodily Injury Claims Management Association, read with great interest the article “In search of confidence” (Post Mag 21st August) by Matthew Beard of Medicess. The article makes some good points but demonstrates some misunderstanding about the dynamics involved in the injury-claim situation and the real role of the case manager. Understandable misunderstanding which merits some comment on the specifics as well as the real needs in the field of rehabilitation.
It is, of course, legitimate to suggest of an industry in its infancy that it has some growing up to do! However, the assertion that the Case Management approach is the wrong model seeks to dispose of more than just the bathwater.
In essence, the complaints are that Case Managers –
• lack the knowledge and expertise to monitor or impact effectively, especially in multi-discipline cases
• are an inappropriate import from abroad
• tend to produce over-expensive programmes based on patient-led information
• fail to obtain GP or hospital notes, which they don’t understand anyway
• attend the patient when they could do what they do by phone
Case Management
Matthew does not say directly with what he would replace the “Case Management model” but we infer that it would be “Doctor-led”, “clinically-based” and “multi-disciplinary”. It would certainly fit the traditional view in the medical profession that because doctors know what’s best (at least from a medical perspective) it is they who should take responsibility for the function which we now call “case management”. That function we in BICMA see primarily as putting the patient at the centre of the process, facilitating all that is required and taking responsibility for the whole outcome – not just the medical one. The requirements are well trammelled and some of the documents are quoted below.
He has encountered situations in which he believes that the best programme has been overlooked in favour of one “patient-led” and unnecessarily expensive. Whether the problems stemmed from a lack of adequate liaison with all involved, or a lack of expertise, the funding party should certainly be encouraged to clarify the rationale with the Case Manager where there is disagreement within the team. Those involved in selecting or agreeing the selection of a Case Manager should of course ensure that the individual has the relevant background and is a member of the relevant professional body, the main ones being The Case Managers Society (UK) - CMSUK, The British Association of Brain Injury Case Managers - BABICM, and the Vocational Rehabilitation Association – VRA. Each of these organisations is very clear in its view that no Case Manager should take on a case for which they lack the necessary knowledge and experience.
The same applies to the assertion that Case Managers don’t obtain GP and hospital notes, and that they lack the expertise to understand them. Each of the Case Management organisations views the obtaining of these records as a vital part of the job and that the job can only be performed by a Case Manager with experience and knowledge in all fields relevant to the case. The Case Manager’s role does not include a requirement to second guess diagnosis. Of course, if there is doubt, it may well be appropriate to seek a second opinion.
The concept of case management was indeed imported in one sense. When BICMA initiated the development of the Case Managers Society in the UK it was clear from the outset that case managers who valiantly shouldered the burden of taking over that organisation and running it would need to undertake a radical revision of the American concepts to enable the principles to operate effectively here, particularly in the UK tort-based claims environment. The result is a unique body providing a sound professional structure for generic case management.
So how do case managers justify their existence?
CMSUK’s Best Practice Guidelines refer to “collaborating with the injured person by assessing, facilitating, planning and advocating for health and social needs” and say that “The case manager is responsible for proactively managing the case”
The BABICM Guidelines and Protocol include, “Co-ordinate and manage the provision of rehabilitation, care, housing, support, equipment etc. Monitor the client’s wellbeing and health and regularly review the quality of care, services and equipment and their continued suitability to the client\'s needs”
The Practitioners Guide to Rehabilitation suggests that the Case Manager’s role in the development of the rehab plan involves -
• Engage the claimant in consensual, fully informed, goal setting and planning;
• Assess the personal circumstances and needs of the claimant and his/her family;
• Monitor medical rehabilitation and, if necessary, provide for multi-disciplinary assessment;
• Monitor psychosocial rehabilitation and, if necessary, provide for assessments and interventions;
• Liaise with the Benefits Agency and claim appropriate benefits;
• Liaise with the local authority for interim support prior to a statutory assessment (currently Community Care Act 1990); review such assessment and negotiate the provision of services and financial assistance from the local authority;
• Arrange for therapies;
• Monitor the needs of the claimant’s family and arrange for respite care, if necessary;
• Assist the claimant in obtaining training and monitoring carers;
• Facilitate employment rehabilitation;
• Arrange appropriate accommodation;
• Review personal transport arrangements;
• Consider mobility issues;
• Consider funding arrangements for rehabilitation.
What is demonstrated here is a unique pivotal role in the process, designed to achieve high quality, cost effective outcomes, and without which the service user falls with remarkable ease through the cracks of a highly fragmented set of services.
Medics may perceive a challenge to their role in the case manager’s view of theirs’ as a “therapeutic relationship” (CMSUK Best Practice Guidelines). Surely the case manager could take on all the “holistic” bits and keep his/her nose out of medical matters?
In reality, the case manager’s focus is on practicalities and outcomes. In that role, s/he neither treats nor assesses medical treatment except in terms of outcome. The relationship with the service user is therapeutic in that the obligations are equivalent to those of all the other therapeutic relationships.
The need for multi- disciplinary assessment in relevant cases is well recognised and in no way detracts from the overall benefit of having one individual at the centre of the process with the injured service user, facilitating their decision making and co-ordinating the rehab process. Realistically, that responsibility cannot be shared out amongst a multi-disciplinary team, however competent.
BICMA is convinced that the individual responsible for facilitating developing implementing and monitoring the rehab plan requires an independence and objectivity which, with the best will in the world, cannot be delivered by those directly involved in providing the various services. It is vital that where that individual is employed by the same organisation their independence is guaranteed by their and their employer’s commitment to the principles set out in the standards of the relevant bodies.
Irritations and Market Dynamics
No doubt the comment that “The industry has over-sold and clinically under-delivered” is designed to provoke discussion and few would say that the garden is exclusively rosy. Amongst the problems described by insurers (invariably the ultimate providers of filthy lucre) we find:-
• rehab reports that propose significant treatment plans which are best delivered by the report writer’s firm. (It is also fair to say that some insurers prefer a “one stop shop” with a trusted provider, foregoing the “purist” approach to “independence” to reduce delay and cost, especially in low level cases)
• INA reports straying well beyond immediate needs
• providers not understanding the legal process in which they carry out their assessments and produce recommendations. (The original concept that rehab is wholly outside the litigation process no longer works in the real world!)
There is also no doubt that some in the insurance industry remain unconvinced in the absence of really good statistical support for assertions of financially rewarding outcomes over significant case numbers, especially in the area of minor injury.
There is a fundamental need for insurers and lawyers to be clear about why they choose to use rehab.
Insurers typically, fall into two distinct categories –
• those who consider the possible benefit in each case, cherry-picking the ones with good prospects of a saving in the total cost of the claim
• those who see benefit in a general policy approach which may not equate to “rehab for all” but is based on the premise that the overall benefit to shareholders gained from the improved outcomes in a proportion of cases, in legal cost savings and in their dealings with their opponents, outweigh the downside of the cases where the time, money and effort was fruitless
The first group tends to be more voluble on the question of “cost effectiveness”, and some have decided for example that Physio generally is not cost effective and have withdrawn or restricted the facility. As a result solicitors are more inclined to direct needy claimants through their own arrangements leaving insurers with little opportunity to influence provision or cost.
From the perspective of the individual case, BICMA considers that the obligation of a tortfeasor to put the claimant back into the position in which he/she would have been, had the accident not occurred, should now be regarded as including reasonably practicable efforts to facilitate the best physiological, psychological and social outcome for the claimant. This could be defined as a duty to ensure access to proportionate services, finance and facilities, at the appropriate time, in the appropriate manner, in so far as these will [or probably will] accelerate and/or enhance rehabilitation, as measured against what would happen without such access
At the least, we should ask ourselves - Will this person make a full or partial recovery without further treatment? Can this recovery be improved or hastened by further intervention? If so, rehab should be considered if the cost of rehab will impact proportionately in the speed and/or level of recovery.
It can hardly be denied that the proportion of cases where a real saving is made is lower at the “shallow end”. The benefits to some are cancelled out to some extent by the failings for others. This much has been obvious from the research literature for over 10 years and has now been emphatically summarised by the recent publication from Waddell, Burton and Kendall aimed at making plain the systematic failings of the NHS DWP and employers. At the minor end of the injury spectrum they regard the failings as more significant than the benefits.
Nevertheless, BICMA’s ideal view is with the second group on the basis that the less adversarial, more consensual, collaborative and constructive approach pays its dividends primarily in terms of improved relationships and a marked reduction in legal expense.
The real needs – standards, measurement, congruence
It should be clear from the above that BICMA doesn’t consider the Age of Enlightenment to have arrived – nor is it a simple “Aha!” moment away. The search for confidence is not over.
Standards
An enormous amount of work has been done and some potentially disastrous pitfalls avoided in the last decade in the drive to deliver insightful, well thought-out and effective standards and professional ethics in case management. In addition, a generic statement of principles applicable to all providers of rehab services is available. However, what remains lacking is uniformity and policing
A great deal is riding on the Rehab Council (UKRC)’s ability to meet the challenge of producing Standards that are relevant, effective and workable in the rehab industry’s current state of development. All concerned should respond thoughtfully to the promised consultation.
Measurement
Huge strides have been made in numerous studies demonstrating situations in which rehab works (“Efficiency of specialist rehabilitation in reducing dependency and costs of continuing care for adults with complex acquired brain injuries” - L. Turner-Stokes, S Paul and H Williams;
“The costs and benefits of active case management and rehabilitation for musculoskeletal disorders”- MA Hanson, K Burton, NAS Kendall, RJ Lancaster and A Pilkington)
Ideally, we should also try to ensure that the benefits to those funding rehab are properly measured. This implies a high level of trust and co-operation between insurers and providers to produce cogent financial statistics
Congruence
Most importantly, it is vital to reduce friction in the process. Aims, infrastructure and contracts should be self consistent within the system. Our objectives include helping insurers to consider the merits of their policy choices. Only with that insight can they give the service provider industry a more intelligent set of requirements and contract positions.
Are we there yet Mum?
Not yet - but there’s no going back!
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