An experienced physiotherapist, Sarah has worked in a variety of specialist rehabilitation roles, including acute care and as a keyworker, coordinating care for individuals with spinal cord injury, brain injury and other neurological conditions. We find out a bit more about her experience and why the move to case management.
You recently moved back to the UK from New Zealand, where you were providing specialist rehabilitation to people who’d sustained neurological injuries, traumatic amputations and complex orthopaedic injuries. What are the differences and similarities between rehabilitation services over here versus New Zealand?
In New Zealand there’s only one corporation that cover all accidents and incidents; the Accident Compensation Corporation (ACC). Everyone in New Zealand pays into this via their taxes. Anyone that comes into the country is covered under ACC for small claims, whether they’re at fault or it’s the fault of someone else. Where time is needed off work, ACC will continue to pay 80% of the injured party’s salary and fund any medical input.
When it comes to more complex cases, injured individuals are allocated a case manager who will facilitate referrals to rehabilitation providers, instead of being allocated a case manager at the rehab provider.
The difference is that case managers in ACC aren’t necessarily clinicians – they coordinate care, but they generally won’t have the depth of clinical understanding that case managers over here do.
The assessment process for catastrophic injuries - which are known as serious injuries in NZ – is very similar. Over there they have a Serious Needs Assessment (SNA) which is comparable to our Immediate Needs Assessment (INA). However, the case manager will refer the individual to a therapist to conduct the needs assessment.
Following assessment, the rehab client will be assigned a different therapist to provide their rehab. The difference is that over here, the rehab is driven by the case manager with a clinical background, so they have a better understanding and can make recommendations.
What is meant by ‘specialist rehabilitation’? What does it involve and what was your role?
Specialist rehabilitation means working with individuals with severe brain injury, post-concussion and other neurological conditions, as well as amputees, and those with spinal cord injuries. My role as a keyworker was very ‘hands on’. I was responsible for coordinating the care and being the main point of contact for rehab providers, case managers and the client’s employer. The end goal was getting individuals back into work and returning to their pre injury social and recreational activities.
How does your experience in rehabilitation in acute NHS settings compare to your experience of other rehab settings?
My most recent NHS rehabilitation role was working in an acute stroke unit, where I would see patients who were 0-72 hours from having a stroke, who required immediate assessment and intervention. In NZ all my rehabilitation work was community based. This included rehabilitating patients back into the community from acute settings and rehab clients who sustained injuries a while ago but were maybe having difficulties adjusting to everyday life. Their needs are at opposite ends of the spectrum and require very different approaches. But because I’ve had experience in both situations, I’m able to understand what the person has been through and the steps that they would have needed to take to get to their stage of recovery.
Why the change from specialist rehabilitation to case management?
The role of a keyworker is similar to a case manager. I enjoyed the challenges of being a keyworker, pulling all the care and everyone involved together to get the best recovery results for every client. Being the main contact comes with its own challenges, but I enjoyed formulating recovery programmes just as much as the hands on rehabilitation experience.
Good communication is vital for both roles and this has always been one of my strengths. This includes building therapeutic relationships and being that point of contact, and I’ve always enjoyed that aspect of things.
Which three qualities do you think a case manager should have?
Empathetic, organised and lateral thinking.
Is there a particular case throughout your career that has really made an impact on you and why?
The first rehab client I saw in New Zealand stands out for me. He was 17 and had been involved in a snowboarding accident which left him with a spinal cord injury. I first met him at a spinal rehab unit. He’d previously been extremely active and was into extreme sports such as snowboarding and surfing, and his goal was to get back to participating in these recreational activities.
Maybe it was his age or his active nature – or both – that meant he was really up for trying anything to help his recovery and extremely motivated to succeed. He’d been dealt a tough hand, but he went ahead and ‘dealt’ with it. He was never going to give up on his goal – he’d never say no to trying out something new and never complained. There were days further on in his rehab where I would take him snowboarding. It’s so important to make rehabilitation relevant for the individual – bespoke to their goals and passions. His determination meant he regained full independence in all aspects of his life. He was able to go back to doing what he loved, including snowboarding and surfing.
You specialise in spinal cord and brain injury - how will you apply your expertise from being a specialist neurological physiotherapist to case management?
I’ve seen lots of different aspects and types of injury across a whole range of individuals who are at different stages of life with a diversity of goals and priorities. For example, with brain injury you see a range of cognitive and emotional symptoms as well as physical injuries. I have good understanding of the symptoms and impairments that may present as a result of these injuries, and expertise in managing these. This will be extremely beneficial in my role as a case manager, as I’m able to anticipate how the injury will impact the individual, predict symptoms that may not yet have presented themselves and identify the best rehabilitation pathway.
My community rehabilitation experience in NZ was focused on getting the individual back to work and independent living, so there are huge similarities between the experience and expertise I’ve developed here, and what I’ll be doing as a case manager.
My breadth of experience from acute care to working with injured clients years after their injury means I understand what the rehab client has been through, which will help strengthen the client-practitioner relationship and build trust to get the best possible outcomes for the client.
Having been a keyworker also means I’m used to working in a team with a range of professionals, ensuring cohesive care plans and effective communication amongst the wider MDT, same as in case management.
What type of symptoms would you expect to see as a result of neurological trauma, and how do you approach these types of cases?
You can get every symptom under the sun - it’s always about taking a case by case approach to assessing what an individual’s needs are. You can look at an X-ray of a fractured ankle and know roughly what to expect as a result of that type of injury, but when it comes to a spinal cord injury or brain injury, imaging won’t necessarily give you that kind of insight – you won’t know what you’re dealing with until you start to see how symptoms present. So you can’t take a formulaic approach to assessing these types of injuries.
How do you balance commercial considerations when it comes to clinical reasoning and decision making?
By advocating the treatment that offers the best possible outcomes and ensuring all decisions are substantiated by clinical reasoning. It’s not necessarily about having the most recent rehab technology or the most expensive provider – it’s about what the individual needs to maximise their recovery.
Tell us a little more about the assistive technology you’ve found successful with rehab clients?
In the past I’ve seen really good results with functional electrical stimulation, particularly when it comes to lower limb function. These send small electrical charges to muscles to stimulate movement, so for example it recognises gait pattern and provides specific stimulation at certain points of contact when the individual is walking rather than having to use a splint. Body weight supported treadmills are also useful in the recovery of the ability to walk after neurological injury.
Communication is essential to independent living and so speech recognition technology is an important way to help rehab clients gain independence.
With both spinal cord and acquired brain injuries, individuals may lose function in limbs. Smart prostheses give them more control over their limbs. For example, certain hand prostheses use electrical signals from existing muscle groups in the arm to control computerised fingers. It’s more intuitive than other types and gives the rehab client more control and a closer return to their previous function.
What’s the most important consideration when facilitating discharge from acute settings to community care?
Making sure the individual has a support system in place. Which means a in depth understanding of what the individual’s needs are in relation to the environment they will be living in. It’s about having a system in place to spot any warning signs of deterioration and a way to communicate concerns and resolve any issues that may occur. Fundamentally it’s about making sure there is the right equipment in place for it to be a safe environment for the rehab client.
What three words sum you up?
Loyal, caring, determined.
Tell us something interesting about yourself.
I’ve lived in New Zealand for the last 8 years, but very recently made the move back to the UK. With the future of travel looking less certain following the pandemic, we decided it would be a good idea to move closer to family – not too close…but closer than 36 hours!
What attracted you to HCML?
It’s innovative and forward thinking in its approach. The use of technology to continually improve the rehabilitation journey allows us to keep up with digital demands of the world and our clients and customers.
Given your experience in dealing with extremely serious cases as a physio, what do you do inside or outside of work to manage stress and remain resilient?
At work I tend to keep as organised and communicative as possible, and it helps to be part of a wider team of people that offer support.
Outside of work my kids who are 1 and 3, takeover and I have to be in ‘mum mode’, so I think this takes my mind off everything else! Being active and outside a lot in my spare time helps too. And eating!
What keeps you motivated and inspired?
People can be dealt very hard hands, and yet a lot of people in really tough situations remain positive and focused on what life could look like after injury. I’ve been inspired by people who have had life changing injuries and despite this, are still thinking about how they can be the best versions of themselves and working towards this.