Like it’s not hard enough!

Dealing with care staff issues and needs during a pandemic: A Brain Injury Case Manager’s story

Have you ever noticed that certain cases make you worry more than others, even if you would class all the cases on your caseload as ‘complex’? It might be those with poor engagement with therapies so poor rehab outcomes feel like they reflect badly on you as a Case Manager? Or it might be the ones with challenging behaviours where risky behaviours make care planning difficult to predict? Or those with difficult family members who fill you with a feeling of dread whenever they call? It might be all the above and more, since no catastrophic injury is likely to leave only a few issues for our clients to endure…

For me, no single other type of case is more challenging than the one where the care team is not well formed and the client has no-one else but the team to care for them: no family, no friends… nobody. Those are the cases I worry about when I’m on leave and have to hand over to a colleague with tons of details… they are the ones I fear for over bank holidays and Christmas and have to make sure the rota is layered with cover which, at certain times, is near impossible to find.

Sarah is like that for me. Now middle-aged, Sarah acquired a brain injury in her late 30s following medical negligence which left her with largely executive functioning cognitive deficits, difficulties with her speech and an inability to walk unaided. For various reasons, she can no longer call on family to assist her. She has therefore had to rely entirely on professional carers to support her with personal care, meal preparation, mobility, social interactions and community access.

When I was appointed a couple of years ago, there was already a care team in place and it was clear that the carers had not been managed well (when Sarah’s family were in place) resulting in gossiping habits, unclear care practices, no supervision and even cash payment of wages. Crucially, Sarah found the team difficult to manage on her own. In informal discussions early on in my appointment, it emerged that some key carers were not enjoying their job and were seriously considering leaving the post. Panic button hit hard!!

What would I do if a carer called up and said “I’m leaving with immediate effect” or “I can’t come in today due to X, Y or Z”?

I’m fire-fighting carer issues all the time. How can I really deal with the underlying structural issues?

Sarah was assessed as not being able to manage her care needs without 24-hour assistance. She would be at terrible risk if someone did not turn up. One acid test of how confident I feel about a client’s care package is: if there were a fire, could the client get out of their home safely? For Sarah, the answer was 100% ‘No’ — she could not get out, let alone safely, without immediate assistance. Panic button hit hard again at this point!!!

Familiar story? What a responsibility to charge ourselves with! But we’re here now, so let’s crack on…

Regardless of whether you are an independent Case Manager or part of a large organisation, carer-no-show in a case like Sarah’s — really in any case where care is heavily relied upon — is a serious situation to manage. Let alone in a pandemic, when carers could legitimately call you minutes before a shift to say they or someone they’ve been in touch with might have coronavirus symptoms. These are the scenarios — ‘worst case’ as they might be — that strike the fear of God into me, but also — perhaps masochistically — are the ones that drive me in this role!!! Remembering that supporting vulnerable people helps that Panic Button start to feel more like a Motivation Button. That immediately reframes my thinking into a more action-based, positive direction.

So, while I don’t have too many cases like Sarah’s, managing care teams remains a major concern and interest for me. I know I’m not unique in carrying this concern. In the wider economy millions of pounds are spend annually on understanding, finding and crucially keeping the ‘right’ person. So I know this is a world and industry-wide struggle and that is no different in the care sector. In fact, right now there are over 120,000 care job vacancies and close to 500,000 carers will leave their job this year. The care industry seems to be a very fluid job market.

If Sarah does not feel confident about her carers staying in their job, she is not likely to feel safe. And we all know that living daily with insecurity is a cruel and harsh way to go through life, especially if your quality of life depended on it. It falls on the Case Manager to manage the teams effectively. But, how do you do it? What can team management look like?

Well, with all these concerns, facts and responsibilities in mind, my team and I have come up with a set of strategies. I wanted to share a selection in the event they can be helpful to you in your practice:

1. Centre yourself — the ride might get bumpy!

While it’s not directly about you, as a Case Manager, you are going to be the messenger, the advocate and implementer. Like it or not, there will be an impact on you and recognising the impact on you is an important starting point. So, and work with me here…

Pause to reflect on how this situation makes you feel, physically and emotionally? This awareness can be used as a tool for you to understand how you might respond and react to the situation you are being presented with. The chances are this reflection will also give you some great insight into how it might be for your clients, their families and the care team itself. You’ll all be feeling the stress and you’ll all be wanting a solution as it’s not in anyone’s interests to carry on. Using this mindfulness to carve out the aims and values of any intervention you implement will help you keep your eyes on the prize, despite distracting factors and thoughts. Acknowledge the pressure and challenges that come up for you, and return to this point. You’ll be amazed how many good ideas will come to you in this exercise, and how much calmer and stronger you can feel about tackling the problem.

2. Appropriately share the key processes of your reflections with the client, family and care team

Nobody likes to make decisions or think about changes in the middle of a panicky situation. Ensure you maintain good communications consistently with the key people you work with before a crisis strikes. This includes those who hold the purse-strings. When a proposal or solution feels co-created, where carers have felt able to offer their opinion which they have felt was heard by those in charge (and Case Managers are part of that stratum of support), it is more likely that change will be smooth. Such communications do not have to be formally set up in any way, but emails, check-ins, regular informal chats and follow-through actions can go a long way in demonstrating how ideas are welcomed from everyone involved.

Asking questions like “what would that look like?” and “how much improvement would you feel if that were to happen on a scale of 1 to 10 where 1 is Not Much and 10 is Lots?” can be really helpful to understand what it is that about the situation that particularly bugs your carer or client. Also how fixable that might be, given what else you know about the situation.

3. Team management

Since keeping a team functioning well is arguably the single most important task of a Case Manager’s job, it is arguable then that investing in the protective factors of the team is well worth doing. Because anyone would agree that constant trouble-shooting, recruitment and training new team members is a horribly time-consuming and expensive, not to mention soul-destroying, business that cannot even guarantee a positive outcome.

There are different ways to consider supporting and therefore protecting your client’s care teams. Indeed, the classic strategies include regular team meetings, supervision and clear guidance. But, even these mainstays need unpicking. What is the aim of your team meetings? Do you use the team meetings as a way to remind us of important values in the work for the client in question? Is there space for discussions, idea-generating, achievement recognition etc? Similarly, is supervision only a tick-box exercise… or is it consciously an engaging experience for you and your carer supervisee? Reflective practice is a huge topic (for another blog post!) that has a strong evidence-base demonstrating it allows for personal and professional growth which increases job satisfaction. If these interactions don’t distract a care team from less helpful behaviours like gossip and stagnancy, then I don’t know what will…!

There isn’t a lot of academic or commercial research on Case Management per se, so I really urge my fellow Case Managers to draw on the literature of how care teams work. There is however a well-established relationship between stress and resilience in the psychology literature. Improving carer resilience means improvements in job satisfaction, team morale and stress. As such, I would argue there is also a role for broader-view, albeit slightly less conventional, approaches in resilience development such as team building activities, personal development workshops, team training and even regular social events (pandemic permitting).

4. Values-based recruitment

I am a true believer in the recruitment process helping set the values that we want to see in a carer. Therefore getting recruitment right is key. I highly recommend utilising the support from the get-go of a HR company that specialises in medico-legal clients (such as Finders Keepers Recruitment) because they understand the context within which we work and the mechanics behind it. However, first and foremost the role of the Case Manager is essential for setting the tone for the whole campaign, and getting it right from the job description will inevitably lead to better staff satisfaction and retention.

5. Some practical tips …

My own company uses telecare-type services for some of our adult clients who have periods without carers, but who will need some kind of support from falls or other unexpected issues. These services usually provide a watch or necklace for the client to wear which has a panic button on it and then alerts a call centre to trouble shoot the issue and will send someone around, if necessary. They’re usually quite cheap at a few pounds a month on subscription, but can provide peace of mind.

In some teams, we have a mixture of agency and directly employed carers as that gives us the flexibility to cover shifts more easily.

In other teams, we have considered an “on-call” level of support where those on-call (for an increased hourly rate) are asked to attend the shift within 1 hour in the case of an emergency with the first level cover.

6. Get an Assistant

I am a big advocate of working within a dedicated mini-Case Management team for each client case where the team is deemed to need a lot of support. I find it too difficult to dedicate one person’s time to all the other aspects of a client’s care and therapy package. Engaging the services of an assistant to support some of the implementation means that the client is able to focus on other tasks alongside. Many independent Case Managers and larger organisations do make use of assistants: it’s more commonplace than it might seem.

If you leave this piece with one thought only, please let it be this: given how absolutely fundamental staffing is to client and family wellbeing, it is a lot to ask of any Case Manager to manage care teams on their own or without support. So, don’t be afraid to put in place strategies that can and will help.

If team wellbeing makes sense to you, check out this resource sheet on building team resilience. It’s got some good tips to help shape your journey with your care team. But, sometimes, it can be that a team needs more of a rejig than a reshape, and it might be time to engage the services of a consultant who understands the psychological needs within personal injury case management. PsychWorks Associates can do this for you — a free consultation with us can tell you how.

Wishing you, your clients and their care teams the very best wellbeing.