Successful community placement
The Great Escape
Lynn Hodge
Director/ Senior Case Manager
Case Management Services Ltd
[email protected]
www.caseman.co.uk
James - Background
 Male, late 20’s, scaffolder
 RTA, GCS 3, multiple fractures
 Traumatic subarachnoid bleeding, contusion
 Fronto-temporal scarring and cerebral atrophy
 Major, widespread cognitive deficits
 Later in hospital stay was showing no coherent response
Presenting problem
 James was in a “young physically disabled ward”
 He had been there for 4 years
 Staff reported, and records indicated, declining
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responsiveness and engagement
At least some staff thought the lack of available therapists
was the cause
Environment provided no stimulation – not even a TV he
could see properly
No outings, never left ward, no therapy
Every time we saw him he was lying in bed mostly asleep
Family
 He has been unmarried, no children
 Local authority have welfare guardianship and there
is a professional Financial Guardian
 His father and other family members in contact
 Family were keen on discharge to community
Pre-discharge reports
Neuropsychologist (NHS assessment):
 Awake but unresponsive.
 Followed person with his eyes.
 No evident eye contact.
 No speech.
 Classifiable as “minimally responsive”
Pre-discharge reports
Neurologist instructed by the defender’s solicitors:
 “At this stage there is in my opinion no prospect of
James recovering to any independence of functioning
and he will remain in need of total nursing care [and
tube feeding]”.
Pre-discharge reports
Rehab Physician instructed by pursuer’s solicitors:
 “In my opinion, he is likely to remain permanently
severely disabled, essentially as he is at present…”
 Would remain disabled and dependent.
Pre-discharge reports
Defender’s Care Expert
 “On balance I consider that it is in the best interests [of
James] and his care that the care should be delivered in
either hospital or specialist nursing care home. I do not
consider that there is any significant gain to be made by
James [living] in a home of his own…”
Pre-discharge reports
Rehab physician instructed by the pursuer’s solicitors:
 “Overall as it is now past the third anniversary of this
accident it is regrettably unlikely that there will be any
significant change…..”
 “I consider that he will be able to live in his own home with
an appropriately trained and supervised care team and
indeed as he has some awareness of his immediate
environment I consider that this move is likely to be in his
best interests.”
Pre-discharge reports
Neuropsychiatrist instructed by the defender’s solicitors:
 Hard to say “if he was truly in a minimally conscious
state”. He “certainly behaved as if he was for long parts
of admission…..[but there seemed to be] a voluntary
component to some of the lack of cooperation.”
 “Some minimal improvement to be expected over the
next few years.”
 “No [clinical] barrier” to domiciliary care.
Pre-discharge reports
Neuropsychologist instructed by pursuer’s solicitors:
 “It seems that at an earlier stage post injury there was a
higher level of responsiveness….. It would seem that he
has been declining in responsive level for some time
now. The view expressed to me [by staff] was that he
has lacked stimulation. I think that he should be
afforded the chance to regain the ground lost….by
having him in a home of his own with a suitable support
team.”
The legal case
 Hospital consultant’s view that he was able to be
discharged to the community with the right support
 His legal team obtained an interim award for a trial
 Defenders argued:
1.
2.
3.
4.
He was not fit for discharge
If he was a nursing home was best as there were nurses
If he went to community he would not need nurses only
carers and they would be hard to retain
So he should have a live-in carer
The practicalities
 To avoid missing court dates, the trial had to be set up
quickly
 We understood this, but the trial had to be done in 3
months – ideally a longer period would be available
 In the event, a successful trial was achieved
The steps
 We involved 2 CMs – one on accommodation and one on
care/support
 Accommodation:
 We had to find a suitable property quickly, on rental basis,
and get adaptations made
 We had to obtain furniture etc
 Lot of liaison over lease, permissions to adapt, etc
 Insurance/phone lines/etc all to be arranged
The steps
 Care/support:
 Identified possible care providers (agencies)
 Shortlisted – practicalities explored
 We had them recruit a specific team to meet his needs and
provided supplementary briefing/training re the specifics of
the case
 Liaison with hospital to have new carers trained in the
hospital
 Worked with hospital team as part of discharge process
 Registered James with local GP, met with District Nurse
 Sourced equipment needed
Life since coming home
 Case Manager
 Care team (from a separate provider)
 Still has 24-hour care, 2:1 support
 Nursing input has reduced and most of care is provided by
support workers
Life since coming home
Input from:
 Speech & Language Therapy (Community Team)
 Physiotherapy (Community Team)
 Dietician (Community Team)
Progress since coming home
 Moved to permanent residence near family
 Regular visits from friends and family & social outings
 Comprehension greatly improved
 More involved with day to day decision making
 Actively involved in his personal care
Progress since coming home
 No longer nil by mouth
 Able to take 3 meals a day by mouth
 Walking using frame
 Is now speaking; words and short phrases
 Much more involved in activities around home
 Has an active social life
Future Goals
 Improve communication using an app for Ipad
 To continue to improve mobility
 James wants peg removed
 James wants catheter removed
 James wants to go abroad on holiday
 James wants to go for a night out in the Savoy
Successful community placement
The Great Escape
Lynn Hodge
Director/ Senior Case Manager
Case Management Services Ltd
[email protected]
www.caseman.co.uk