Setting goals with clients – insights from a Case Manager

In the multifaceted role of a Case Manager, how do we enable clients to set goals without managing the goals ourselves? How do we ask the right questions to ensure we are hearing their frustrations and guide them towards a path which motivates them?

ILS Case Manager Eleanor Clarke discusses her client centred approach to meaningful goal setting and innovative case management practice.

If I were in a client’s situation and someone approached me and asked, ‘What are your goals?’ I wonder what my answer would be. A client with a brain injury initially might find it easy to come up with a goal, but they will be huge ambitions like walking, talking or going home and spending time with family.

Then, as time progresses, it becomes harder and more complicated – ‘to be left alone by professionals’ might well be in there as well as going back to work or driving.

There are often many undiscussed complex whirling thoughts of sexual and emotional needs, intimate needs. Private thoughts that previously the client never discussed, except possibly with a close friend over a beer or glass of wine. Certainly never with a professional with a lanyard.

How do we break those barriers, talk about accessibility difficulties, create real client goals, and write a working document? Not a just a clinical goal which is reviewed once every six months to ensure funding is continued.

Everyone has had that moment in life when you’ve spent ages trying to push open a door which then easily pulls open. That moment of acute embarrassment – or is it frustration – with oneself or annoyance or just irritation with the world? It is moments like this that make me realise that everyone has accessibility needs.

I see my job as a Case Manager for catastrophic injury to assist clients to overcome accessibility difficulties whether that is in their home, at work, college, in recreational activities or personal ones.

Often our job is to assist them to understand their needs and work with them to identify how they move forward and find unique solutions for them, Case Managers have the clinical knowledge to bring in experienced therapists or professionals as required and setting the necessary goals.

Truly client-centred goal setting is hard. The discussion around goals is an art form, an open conversation, a question of where you see your life going, an acknowledgement of how tough this can be and taking in the unique complexities for each person. It is a non-judgmental unbiased sharing of information regarding the opportunities available and what I as a Case Manager can do to support them. It includes gentle regular reminders (to both the client and litigation teams) that as a Case Manager we are here for our clients and that we need to establish and communicate how they want us to work for them.

Factors to consider

Are you the right person for the role? Can you discuss all the areas openly and honestly without embarrassment or judgement. If not, can you signpost to someone who can?

I recall a conversation during a meet and greet with a young client at her home. She was barely 19, going off to university looking to find her first case manager to support her as she left her family home. We were sitting in her kitchen chatting and we discussed just that. That she needed to trust her case manager, feel comfortable with her and feel confident that she could talk to her and set goals with her and that the case manager would action them appropriately.

Empowering her to lead a fulfilling life in all areas, not just therapeutic ones, opening her life from her currently sheltered family life to a supported young adult life. That young lady chose a different case manager that day and I hope I helped to empower that decision.

The examples which follow show how an ability to ensure that your client feels listened to and understood as well as having the confidence in my ability to help and support them, is essential to providing effective Case Management. It is a big and crucial part of what makes the Case Manager role so varied and rewarding.

Jacob

The need to achieve goals and create further goals during long-term rehabilitation and the litigation process can be frustrating for clients and the case manager alike, often feeling like it is a line of endless hurdles to jump like an Olympic champion. But with perseverance and lateral thinking it doesn’t always have to be a line of hurdles.

Working with Jacob over the last year has at times been really challenging. It had become clear he was losing significant motivation for his rehab programme and he expressed his wish to cease his OT, psychology and physio input. He was becoming disengaged and demotivated with the progress he had made.

I knew that I needed to show Jacob that I really listened to him, that his views mattered and were central to the case management process. Whilst respecting his views, it was my role to enable Jacob to identify things he was motivated to achieve. We changed tack and went down the route of hobbies. He was a keen golfer and skier prior to his accident. Through supportive listening I was able to understand what motivated Jacob and we were able to establish meaningful goals together. He was not motivated to have therapy, however he was motivated to return to Golf and Snowsports.

Advocating for him throughout, consistently highlighting Jacob’s views and priorities to others involved in his rehab and legal professionals helped him to reengage, take back control and move things forward at his pace.

Now we knew what he wanted to do it was my job to identify how Jacob could make progress to achieve those goals. We agreed that he would need to work on exercise tolerance, upper limb range of movement, balance, and strength. We talked about Physiotherapy, OT, podiatry and orthotics, input to enable him to work towards his goal of playing a round of golf. For Jacob, attending golf lessons was hugely more motivating than attending a physio session but the physical benefits were of a similar nature. He engaged and made great progress. The orthotics were a success in his golf shoes will now be used in his ski boots with ski lessons at the snowdome being the next goal to work towards!

The journey towards achieving goals can at times be frustrating for both clients and the Case Manager, but the winning moments along the way can be so rewarding. When Jacob, who has exceptionally complex physical restrictions and emotional challenges, asked for his physiotherapist to attend one of his golf lessons, it all seemed worthwhile. This moment caused me to pause and smile. Jacob had previously disengaged with all therapists and had often been reticent to talk with me, preferring to ‘return to normality’ as he put it and push on with his life. It felt like he now could see how tailored therapy could support him in a real way to achieve his goals.

Mark

Mark disengaged with therapy, he was able, despite significant cognitive and communication difficulties, to describe why he did not like the exercises from physiotherapists and that he found them boring. His family and physiotherapist were keen on him continuing with more traditional physiotherapy but for him that simply was not an option. We needed to identify what he did want to do and how we could weave physio into those activities in a way that supported his needs. Following discussion, he set a goal of going horseback riding. With the family and team on board, a hippotherapist was sourced and a trial session planned. He is now able to achieve the same benefits of a more traditional physiotherapy exercise programme whilst riding a horse which he finds more motivating and engaging.

Trevor

Trevor is a young man with a severe TBI and very complex needs, He is imposing to look at, apparently confident and larger than life and really enjoys a joke. One to one, he can focus and discuss goals and prepare for a meeting. However, his goals are tangential and complicated, often related to his sexual needs, desire for female company and a craving for love and attention. He has grand plans for work which I have no desire to quash, as it is not for me to determine if they are possible or not. Using these plans, we were able to set goals ahead of a discharge planning meeting. We were ready and Trevor had what he wanted to say prepared.

I watched Trevor closely during the meeting and a whole new persona took over. He appeared meek and confused, listening and nodding and unable to state the goals he wanted to complete and say where he wanted to live. As a supporter and advocate I was pleased when he asked me to speak on his behalf about the goals, we had discussed to aid his discharge planning whilst he sat quietly by my side, until we left the room and the true Trevor returned.

It is moments like these that I realise that a Case Manager wears so many different hats, but fundamentally they are all about enabling clients to be the central point, the hub for all input, the Case Manager providing the spokes.

In summary

Case Managers need to listen, communicate, and assist clients with navigating the difficult path they often have to negotiate through the new world they find themselves in following a complex life altering injury.

We need resilience, tenacity, creativity as well as clinical skills in order to enable their clients to overcome challenges presented by their own particular situations. Our role is to listen and find ways to enable them to progress and engage in the rehabilitation process by focusing on the things that are important to them.

Setting unique and motivational goals for each client is a major challenge for a Case Manager. Without a client-centred approach, openness to new options and flexible thinking, my role as a Case Manager would not be possible.

Each client brings their own unique goals and sometimes they are easy for them to identify sometimes very hard, sometimes easy to achieve sometimes incredibly challenging and more complicated to achieve, I personally think the latter is more rewarding.

This article was also published on www.nrtimes.co.uk on 1st November 2022