CASE MANAGEMENT

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CASE MANAGEMENT ACQUIRED BRAIN INJURY

• Jasminka Vuckovic-Kosanovic,
• arbias

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About ARBIAS

• Specialised services in the alcohol and
  substance related brain injury field.
• This includes
• Case Management (outreach case management and
  FFS)
• Specialist Consultation Services
• Neuropsychological Assessment
• Recreation Services
• Specialist Accommodation
• Attendant Care Services
• Training Education Services

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Definition of ABI

• ABI is injury to the brain which results in
  deterioration of cognitive, physical, emotional
  or independent functioning.
• It can occur as a result of substance abuse,
  trauma, hypoxia, stroke, infection or
  degenerative neurological disease
• Impairments to cognitive abilities, sensory or
  total functioning can be either temporary or
  permanent and can cause partial or total
  disability or psychosocial maladjustment
• (National Policy on Services for People with
  Acquired Brain Injury,1994)

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Causes of ABI

• The causes of cognitive impairment as a result
  of alcohol include
• Neurotoxic effects of alcohol
• Nutritional Deficiency
• Cerebral trauma
• The extent of Alcohol Related Brain Injury can
  range from mild to severe and can vary from
  person to person
• Early phases-decrease in cognitive physical
  functioning
• Latter phases unable to care for oneself ,
  severely disabled

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Most Common Issues

• Compared with the general population, people
  with an ABI are more likely to present with
• Significant behaviour problems (e.g. impulse
  control, lack of social skills, self-awareness
  and loss of insight that often cause the greatest
  concern)
• Challenging behaviours may manifest as
  agitated, difficult, inappropriate and /or
  aggressive behaviour (e.g. verbal and physical
  aggression against the self, objects and other
  people, it may range from sporadic explosive
  outbursts through to constant irritability and
  anger)
• Other behaviour changes include inactivity and a
  lack of motivation

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ABI Co-morbidity

• People with ABI are more likely to suffer from
  mental health problems
• Mental health problems might precede the brain
  injury or might occur as a consequence of having
  experienced an ABI (e.g. anxiety, major mood
  disorders, adjustment disorder and drug and
  alcohol addiction)
• Brain injury itself can cause symptoms similar to
  syndromes such as psychosis and dementia.

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ABI Chronic Health Conditions

• The physical difficulties associated with ABI
  are
• chronic liver diseases,
• diabetes,
• nutritional deficiency,
• sensory disturbance,
• decreased balance coordination,
• immobility

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ARBIAS Demographic

• Data collected from the 536 Neuropsychological
  Assessments conducted during 2004/05 indicated
  that
• Males reported in 78 of referrals
• Females reported in 22 of referrals
• DSM-IV-Axis I Clinical Disorder totalled 55 of
  all referrals (e.g. Mood and Anxiety Disorders,
  Schizophrenia, and Substance Related Disorders)
• Active alcohol and other substance use reported
  in 68
• Contact with criminal justice system 25 of all
  referrals
• Provision of arbias consultancy services received
  50 of all referrals
• Provision of arbias case management services
  received 30 of all referrals

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General ABI Data

• Severity of brain injuries was
• Mild (38)
• Moderate (35)
• Severe ABI (27)

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ARBIAS Case Management Model

• Client-centered approach
• Coordination of multi-disciplinary services
  within a community that promotes more
  effective, positive and sustained outcomes for
  people with an ABI  
• Active participation and empowerment of the
  client or the clients designated representative
  (e.g. guardian) in all aspects of identifying and
  meeting client/ family needs 
• Collaborative process that holistically enhances
  the cognitive, physical, psychosocial, and
  vocational needs of individuals with acquired
  brain injury

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ARBIASCase Management Matrix

• Multi-Step Process
• Neuropsychological assessment and ABI diagnosis
• Allocation to case manager
• Case manager and client developing rapport
• Tailoring individual care plan for clients needs
• Linking with appropriate community services
• Implementing and co-ordinating of treatment
  goals
• Advocating
• Monitoring and evaluating
• Planning Case Closure
• Case Closure

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Aims of the ARBIAS Case Management Services

• ARBIAS Case Management Services continue to work
  towards an increased range of case management
  models and practices to better meet our client
  needs including consultation, crisis intervention
  and long term support when required

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Case Study

• 45 year-old divorced , woman was referred to
  arbias by hospital requesting a
  neuropsychological assessment
• The client commenced regular and heavy alcohol
  consumption at the age of 30, on average one
  750-ml bottle of spirits per day with some
  occasional use of heroin over the past two years
• Medical summary indicated a history of Hepatic
  Encephalopathy -chronic liver disease secondary
  to heavy ethanol misuse, decreased balance
  coordination as well as a history of depression,
  anxiety with frequent panic attacks, and
  intravenous drug use, and deteriorating ability
  to cope with functional tasks on a daily basis

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• Current medication include Methadone-pharmacothera
  py, Oxazepam, and Thiamine
• General functioning unable to use public
  transport, problems with attending to personal
  and domestic daily living skills, unable to
  manage finances and budgeting, socially isolated
  with an inadequate social support system
• Accommodation homeless, evicted from mothers
  place
• Legal issues restraining order in place against
  the client
• Hospitalized 3 times in 6 months due to health
  complications and excessive alcohol consumption
• Admitted 2 times into Detox during that time

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Neuropsychological Assessment diagnoses

• arbias Neuropsychological Assessment diagnosed
  brain damage with moderate to severe deficits
• Neuropsychological Assessment recommended
  specific case management strategies to help
  compensate for changed abilities

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Case Study Moderate to Severe ABI
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Case Study Compensatory Strategies

• Case management interventions for an ABI are most
  successful when they are structured, systematic,
  goal-directed and individuilaised.
• Information should be concrete and specific
• Allow plenty of time for respond
• Do not pressure
• Written and verbal prompts , use calendar,
  timetable
• Step by step approach (if this happens these are
  the consequences)
• Work on one behaviour- on one issue at a time
• Uniformed approach from stakeholders
• If there is behavioural contract in place
  continue to use repetition and remind to go back
  to that

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Case Study-Interventions

• Applied ABI Compensatory Strategies
• Applied some harm minimization strategy (focus
  on abstinence, daily Thiamine tablets)
• Both mobility aids walking stick and referred to
  a Physiotherapist
• Applied for Administration Order
• Organised Attendant Care Worker to assist with
  daily living skills, shopping and transport to
  appointments
• Organised Meals on Wheels and linked with a
  Nutritionist

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Case Study Interventions

• Applied for Support and Choice and /or ACL
  financial packagesDHS Disability Sector
• Referred to the following ABI and AD services
• -ABI Behaviour Consultancy for further
  behavioral modification
• -Woman Sobriety
• -Alcohol Drug Counselling
• -AD Residential Rehab
• - Headway Victoria ABI Advocacy

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Case Study Outcomes

• Client medically stabilized
• Abstained from alcohol with the support from
  Women Sobriety groups
• Improved physical safety and quality of life
  (improved mood and level of independent
  functioning)
• Improved behavioral issues by behavioral
  modification and contracting
• Currently in AD Residential Rehab
• Cognitive improvement limited however further ABI
  contained

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Service Needs of people with ABI

• Case Management for people with ABI often
  requires a combination of behavioral, medical,
  environmental and financial interventions
• (National Institute of Health, 1999)
• The support needs of people with an ABI requires
  a range of services such as disability services,
  alcohol and drug services, specialist ABI
  services, primary care provides including general
  practitioners and community health services

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Collaboration and Partnerships

• Develop effective clinical strategies and
  framework that must act in a co-operative
  fashion in implementing best service outcomes for
  clients with complex presentations like ABI
• A wide variety of government agencies,
  non-government services and community agencies
  need to be involved in minimising further harm
  caused by alcohol
• Maximise opportunities for inter-sectorial and
  multi-disciplinary approach

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Acknowledgements

• arbias Staff
• arbias Senior Management

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Contact Details

• ARBIAS
• Phone [phone]
• Fax [phone]
• Postal address P.O. Box 229, Fitzroy, VIC
  3065
• Website www.arbias.org.au