After receiving a referral, all relevant medical records and case information is gathered, compiled, and reviewed. The case is then assigned to a case manager who contacts the survivor and/or a close family member to set up an Initial Assessment.
The Initial Assessment usually takes place in the survivor’s home or current residence. The case manager performs a thorough evaluation of the survivor’s needs, strengths, weaknesses and limitations.
Based on the assessment, the case manager compiles a proposal. The proposal includes:
Results of the initial assessment, including data on survivor’s psychological, behavioral and physical status, basic needs and impairments.
A detailed case management plan, specifying long term and short term goals, schedules and procedures for monitoring progress toward accomplishment of goals and objectives
Follow-up notes, feedback or recommendations from brain injury specialists, neuropsychologists, behavioral therapists, physicians and other outside individuals.
A list of helpful resources along with referrals to trusted agencies to provide additional services
A cost breakdown of the care plan for one year.
Care Plan Implementation
Once the proposal is approved, the case manager implements the care plan by identifying the appropriate care givers and provides training on specific requirements of the case. They will also contact local agencies to set up resources, activities and additional services that aid in the survivors care.
The case manager’s goal is to build a “therapeutic and trusting relationship” with the survivor and his/her family and will always be available to provide support, guidance and solutions when difficulties arise.
On Going Monthly Telephone Support
The case manager contacts the survivor and/or his or her family via telephone each month to follow up on their care and to make sure their care plan is being followed as planned. A monthly progress report is provided to ensure progress toward accomplishing goals are being met, as outlined in the initial assessment and care plan.
Every six months, the case manager visits the survivor in their home to ensure services continue to be met. Case Managers perform a reassessment of the survivors physiological, behavioral and physical status, basic needs and impairments, and adjust the care plan as needed. Short and long term goals are reviewed and reevaluated at this time. Progress is then communicated back to their physicians, behavioral counselors and caregivers.