Case Management and Dual Diagnosis
Margaret Onus Christchurch 2007
NSW
• SYDNEY
Case management
1. Support 2. Education 3. Advocacy 4. Linking
The project origin:
anecdotal stories of incidents due to over indulgence of alcohol presenting with a second or third TBI medical referral a number of years later after long term use of alcohol to rehabilitate self
“seize the moment”
to use case management interventions to manage alcohol issues increase our efficacy strengthen our resources / skills
Goals
Alcohol focus Three tier approach
– –
–
gather literature about co-morbidity develop a clinical pathway to understand our response patterns via a case audit determine the need for further changes
Literature
Tate (1999) - etiological role of alcohol
Kolakowsky-Hayner (1999) - 42% heavy drinkers
Horner (2005) 1 year follow up - 30% moderate to heavy drinkers
Kreutzer (1996) 8 month follow up - decline 28 month follow up - pre injury pattern
Westmead follow up study
60 57
50 41 40
Percentage %
35
30
20
16 8
17
18
10
8
0 6 months non-drinkers social-drinkers heavy-social 24 months problem-drinkers
Cognitive inaccessible
high levels of motivation commitment to appointments self awareness cognitively robust
Howlett, K. (1995) Survey into the Accessibility of Alcohol and Drug Services for people with ABI. Funded by Health and Community Services Disability Program Victoria
Project – part 1
literature Folder – readings
internet resources and sheets
-www.adf.org.au -Ceida(Centre for Education and Information on Drugs and Alcohol) funded through NSW Health
BIA Queensland – www.braininjury.org.au Synapse magazine and self help publications
Project - part 2
Audit of client files
–
–
small sample of 30 clients information was gained from:
Neuropsychology Assessments Medical records
Pre injury alcohol use
30% 40%
30%
Nil/light
Moderate
Heavy
Alcohol audit: pattern post injury
10%
20%
70%
Nil/light
Moderate
Heavy
Established pathways
medical education referral to D & A services “promise” - “problem drinking” timely awareness – enabling change
Enhancements
linking – local D & A service through case management expanded education enabling change through modified counselling/ motivational interview
Change process
curiosity question
Tell me how you are making out now at home/ not driving/ not working or filling in your extra time?
Change process
normalising - reframing “Some of our clients report that they find alcohol seems to affect them differently to before the accident. Has this happened to you?”
Barriers to change
limited insight impulse control limited problem solving capacity
Information
aggression social disinhibition speech coordination cognition
Consequences
advantages and disadvantages
– – – – –
work social capacity to drive future health financial
Awareness
alcohol use and contribution to injury cumulative effect of injury impaired self monitoring
Case study
case management process re-adjustment to community /lifestyle self referral to local service
Case study
education - expanded notes raising self awareness behavioural change road