In this article Jason Chidwick, specialist rehabilitation case manager and amputee clinical lead at HCML takes a look at limb loss and the rehab and needs assessment that follows on from this procedure.
Data tells us that major limb amputations in the UK are on the rise. This increase is largely down to diabetes diagnosis where in some more serious cases the blood vessels in the limbs have been damaged by high blood sugar levels, cholesterol and blood pressure. However, of the 5,000 to 6,000 major limb amputations performed each year according to NHS statistics, other causes are traumatic accidents such as traffic collisions, workplace accidents, and incidents involving machinery or heavy equipment. As a specialised amputation and rehabilitation case manager, I have experience dealing with a whole range of clients from journalists caught in crossfire while covering the Ukraine war to individuals involved in horrific car accidents. As we head into Limb Loss Awareness Month it is interesting to consider how case managers and insurers can work together to ensure the best outcome for the client.
Amputation is a niche area and actually the percentage of individuals who have had major amputation is minimal therefore there is certainly a lack of understanding surrounding the support needed by individuals in their treatment and rehabilitation. This is why the relationship between the rehabilitation case manager and the Insurance case manager is so important. To understand the client’s often complex needs can be a daunting process for both the insurer and the client. If the client doesn’t get the most appropriate products or is not guided properly through the process they won’t reach their full rehabilitation potential.
The first part of the relationship sees the amputation rehabilitation case manager complete an initial needs assessment and provide this to the insurer to detail the clients immediate needs. The rehabilitation case manager will have been liaising with the healthcare provider and have worked with them on an initial assessment of the individual’s needs, goals, and medical history. Based on this assessment, they develop a personalised rehabilitation plan, outlining the necessary medical treatments, therapies, and support services. The case manager will then collaborate with the insurer to review the plan, and then the insurer is able to authorise appropriate funding. During the INA process the case manager will advise on the surgeries the client has had and if any further surgery is planned and most importantly the potential prosthetic devices and/or assistive technology that may be needed as well as long and short-term medical care and other therapeutic disciplines going forward. This will be based on the medical evidence they have access to at that stage of the process.
Of course cost is always a part of all discussions and can be a very emotive subject. Addressing barriers to necessary service access can be tricky and more so now than ever is a fine balance to get right. The insurer works closely with the case manager to authorise and approve coverage for medical treatments, therapies, and prosthetics required for rehabilitation and mobility. As a case manager we advocate for the individual’s needs and that means providing clinical justification and also ensuring that there is supporting documentation to secure insurance approval for those essential services and interventions needed for the client. We also look closely at all types of rehabilitation pertaining to the particular patient’s amputation and determine the appropriateness of that rehabilitation programme and any surgical interventions needed and discuss with the insurer.
CASE STUDY
An example of this is a recent case involving a client who was struck from the rear at 60 mph by an HGV as he was sitting stationary on his motorbike. He suffered catastrophic injuries and medics were unable to save his leg. He underwent above knee amputation but then developed a bone infection and had to have a further amputation. Prior to the incident he was a very active football coach and runner. He was given an NHS prosthesis after 10-12 weeks but didn’t get on with it as it didn’t allow him the level of function he needed.
As the case manager I was able to use my knowledge and expertise within the prosthetics market, and within five months he had a trial of Genium X3 knee. Immediately his gait was much better and psychologically he was able to move forward and physically achieve more. This prosthetic was sourced privately and we worked closely with the insurance case manager who approved the purchase. The knock on effect is that the rehabilitation process is quicker and more efficient and that aids both the healthcare providers as well as the insurers.
If we can get the rehabilitation process right and source the right prosthetics and care for the client at the beginning of the process then it means that it is a more efficient process for all involved. It is important to note though that as innovation happens we do need to consider new products for a client regardless of where they are in their rehabilitation journey. For this particular client we have now moved forward in our support for him and discovered the Evanto foot which gives him more movement and adapts to the terrain he is walking on to give him a more fluent and natural gait, alongside reducing his energy expenditure. The Evanto foot is like a natural foot and the client can walk heel to toe and play sports. In fact this particular client is now setting up the GB paddle disability tennis team which just shows how the right prosthetics can be life changing in a positive way and coupled with the best healthcare and rehabilitation can have great outcomes for the client.
There are so many advances that we have to assess them all in relation to our individual clients. However, all this innovation means that although the patient may have sustained life-changing injuries, advanced robotics and specialised prosthetics could mean that those injuries do not become life-limiting.
COMMUNICATION
The effective coordination of care between the amputation rehabilitation case manager and the insurer is essential in ensuring that the client has a chance at the best recovery outcome. It is not always the case that the newest innovation is the best. Very often it is about what suits that client. Sometimes something very innovative is over functional for the patient and won’t aid their rehabilitation as well as a more simple prosthetic. There are so many advances that we have to ensure and assess them all in relation to our individual clients.
The case manager is there to help the insurer navigate the relationship between the client and the healthcare providers and ensure that the care is integrated throughout the treatment process. Specialist amputee rehabilitation case managers are best placed to help individuals access specialist amputee care. They have a deeper understanding of the challenges faced by clients who have lost a limb and other physical health needs which may happen as a result of limb loss. They also have specialist knowledge and experience in prosthetics fitting and rehabilitation as well as an understanding of what mobility aids and equipment or assistive technology the client may need in order to lead a happy and healthy mobile life. If you had a brain injury you would seek treatment from a brain specialist. It is the same with amputation. In order to fully rehabilitate the client a knowledge and understanding of the best products on the market is imperative.
Rehabilitation in terms of limb loss is tricky and there is no one size fits all. Losing a limb affects individuals in different ways. The case manager and insurer collaborate to identify and access additional resources and support services that may benefit the individual during rehabilitation. This may include vocational rehabilitation programs, peer support groups, community resources, and financial assistance programs. By leveraging their respective networks and expertise, they can help the individual address various needs and challenges beyond medical treatment. Case managers are on hand to navigate the physical and occupational therapy and psychological support that is critical for helping clients adapt to limb loss and regain function.
This article was written by Jason Chidwick, Specialist Rehabilitation Case Manager and Amputee Clinical Lead at HCML, MSc Football Rehabilitation, BSc (Hons) Sports Rehabilitation. Professional member of CMSUK, BACPAR and BABICM
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