Stiekema Annemarie P M, Bierlaagh Desiree, Donkervoort Mireille, Jansen Natska, Jurrius Kitty H M, Zadoks Judith, Van Heugten Caroline M
Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands.
Limburg Brain Injury Center, Maastricht University, Maastricht, The Netherlands.
Int J Integr Care. 2025 Jul 7;25(3):6. doi: 10.5334/ijic.8650. eCollection 2025 Jul-Sep.
People with acquired brain injury (PwABI) and their families may face psychosocial problems and unmet needs. We assessed the feasibility of Case Management (CM) for PWABI in the Netherlands which aims to facilitate access to and integration of health care and social services for people with complex problems.
We evaluated if CM was delivered according to plan, if participants and case managers (CMrs) were satisfied with CM, and which factors affected implementation. Data were collected using evaluation forms, logs and minutes, and interviews.
Twenty-eight PwABI, 13 caregivers, 17 CMr and all 3 project leaders participated. CM key elements were applied. PwABI and their caregivers generally expressed satisfaction with CM, though for some it did not meet expectations. CMrs valued the continuous involvement and the ability to support family. Facilitators were CMr working independent from existing care services and the diversity in expertise in the CMr teams. Barriers were imposed when a region offers medical stroke care but no integrated long-term services after brain injury.
It is important to ensure clear communication with PwABI and their family regarding the roles of CMr, as well as managing and aligning expectations.
CM after ABI is feasible and warrants further research.
获得性脑损伤患者（PWABI）及其家人可能面临心理社会问题和未满足的需求。我们评估了荷兰为PWABI提供病例管理（CM）的可行性，其目的是为有复杂问题的人提供获得医疗保健和社会服务的便利并促进其整合。
我们评估了CM是否按计划实施，参与者和个案管理员（CMrs）是否对CM满意，以及哪些因素影响了实施。使用评估表、日志和会议记录以及访谈收集数据。
28名PWABI、13名照顾者、17名CMrs和所有3名项目负责人参与其中。CM的关键要素得到应用。PWABI及其照顾者总体上对CM表示满意，不过对有些人来说它未达到预期。CMrs重视持续参与和支持家庭的能力。促进因素是CMrs独立于现有护理服务开展工作以及CMr团队专业知识的多样性。当一个地区提供中风医疗护理但脑损伤后没有综合长期服务时，就会形成障碍。
重要的是要确保就CMr的角色以及管理和协调期望与PWABI及其家人进行清晰的沟通。
ABI后的CM是可行的，值得进一步研究。
