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​Clinical Care Managers Piece Together the Puzzle of Catastrophic Injury

March 30, 2016

The effects of a catastrophic brain or spinal cord injury extend far beyond the physical damage to the body. These injuries can wreak havoc on a family emotionally, financially, spiritually and even logistically.

Craig Hospital’s Clinical Care Managers (CCMs) work tirelessly to help families regain their sense of balance by coordinating all aspects of their situation, both at Craig and beyond.

“Our CCMs do a huge variety of things for our patients,” says Stephanie Percival, director of Clinical Care Management. “Each patient who comes through our doors is a puzzle, and each patient’s puzzle pieces are a different shape.”

As every patient and family are unique, it’s important that rehab programs treat the whole person and family. Addressing psychosocial care includes individual counseling and family counseling, group support, education and empowerment, and meaningful recreational pursuits. The overall goals of psychosocial adjustment is for the individual to re-define themselves after injury, to become productive again in a meaningful way for them, and to financially, emotionally, and socially adjust to their “new normal”. The process of re-definition and adjustment can take months or years, and is a continual lifetime challenge, but the foundation for successful adjustment begins in the first months within a powerful positive culture of specialized rehabilitation. CCMs are critical to the oversight and advocacy of this process.

Percival refers to her team as the hub of a wheel, working to address the various psychological, cultural, social, and financial issues each family is dealing with. When a patient is admitted to Craig, they are assigned an inpatient care manager, who will complete an initial assessment to identify and address the family’s immediate needs. These can range from finding child care for a patient’s children near the hospital to arranging interpreters so family members can take an active part in their loved one’s care.

The counselors — most are licensed counselors and social workers — will conduct a thorough psycho-social assessment with the patient and family and counsel about grief, adjustment and even marriage issues.

As a patient progresses through his or her rehabilitation, the CCM team coordinates with the patient’s insurance company and any case managers, discharge planners or law enforcement and legal professionals who might be involved in the case.

Counselors take a holistic look at the family’s financial situation and search for resources that can help them, ranging from a patient’s existing accidental death and dismemberment or short term disability policies, victim’s assistance funds, or homeowners insurance policies. The team also processes Social Security applications for each patient.

When the patient nears discharge, the counselor works with the family to ensure that there is a plan in place and that patients are able to go home to an accessible, well-equipped space. If the patient lives within 60 miles of Craig, the counselor, along with a physical and occupational therapist, will do a home visit to offer advice on home modifications. If a visit to the home is not possible, the team can work off of measurements, blueprints and photos to coordinate with construction contractors. When a family is unable to pay for needed renovations, the CCM will scour for resources, apply to the Homebuilder’s Foundation for assistance or will work with groups of volunteers to get the work done.

CCMs also make sure patients have the durable medical equipment they need at discharge, and they coordinate other patient care requirements, including home health care, outpatient therapies, primary care physician visits, disposable supplies and oxygen.

“There is no easy way to explain what we do — it’s so abstract, so out of the box,” says Percival. “We’re like Julie McCoy on the Love Boat, making sure everyone and everything is in place.”

Each inpatient CCM handles up to 10 patients and their families at a time and follows the family post-discharge for up to six months.

“Inpatient CCMs have an open door policy,” says Percival. “Though many times we have appointments, we see our patients and their families all the time, sometimes multiple times per day as we work on their issues.”

The Clinical Care Managers also access money from the Craig Hospital Foundation’s Patient Assistance Funds, using these donor-supported funds to assist their patients in need. These funds help patients with minimal income or inadequate insurance to purchase adaptive equipment, remodel homes for accessibility, arrange for transportation, pay mortgages or utility bills, and meet other urgent needs.

According to Percival, these funds are a great benefit to Craig Hospital patients.

“On occasion peers at other institutions have asked me how we can do all this, and it’s because of the donor support,” she says. “Patient Assistance funds keep people in their homes, they get people the equipment they need, they allow our families to take a deep breath, and they keep things from falling apart.”

“The Patient Assistance funds help our Clinical Care Managers move our patients and their families from a catastrophic situation to a manageable one," Percival adds. "It allows us to provide comprehensive care from start to finish.”

There is no easy way to explain what we do — it’s so abstract, so out of the box. We’re like Julie McCoy on the Love Boat, making sure everyone and everything is in place.

Stephanie Percival, Clinical Care Management Director

An Afternoon in the Life of Outpatient Clinical Care Manager Victor Towle

11:30 p.m.: Towle talks with a Workers’Compensation case manager to ensure that a patient’s upcoming visit will be covered by the company. “I have a patient who is coming from out of town to be checked out before he begins a driving program,” says Towle. “I have to make sure that the insurance checks out and that things like this don’t fall through the cracks.”

1:30 – 2 p.m.: Towle completes paperwork and drops by the CNS medical clinic on the first floor. He is looking for Dr. Balazy, Craig’s medical director, because he needs him to order a MRI for a patient who is suffering ongoing pain. Dr. Balazy isn’t in, so Towle promises to return later.

22:45 p.m.: Towle meets an outpatient in the temporary clinic in Craig’s big gym. He sits in on the patient’s doctor appointment, along with Craig pharmacists. “I always sit in on clinic checks, because that’s the time when we discuss what the patient’s needs are, and I can get doctor’s order right there,” Towle says. “We solve so much during those short appointments, and I learn what I need to follow-up on.”

2:452:50 p.m.: Towle drops by the CNS office again. Dr. Balazy is still in a meeting, so Towle leaves a detailed message for him.

2:503:15 p.m.: Towle runs into Nina Jensen from the Community Reintegration program. The two discuss a patient’s application for Social Security. “We get to interact with everyone, from doctors to therapists to folks in our support programs,” says Towle. “It’s a fun part of the job.”

3:155 p.m.: Towle updates patients’ medical charts and returns phone messages and emails. He spends time researching mental health resources in a patient’s community and contacts a clinic for authorization to make a referral. “I’m really the right hand for the medical staff. I work with insurance companies and billing departments, I provide information about social security and benefits, and I even counsel my patients on mindfulness and meditation,” says Towle. “I do everything that everyone else doesn’t do — I’m helping patients move from therapy as a lifestyle to life as a lifestyle.”