3/16/2018 topic 1: preparation & interview · questionnaires repetitive movement testing...
TRANSCRIPT
3/16/2018
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I N C O S T O F F U T U R E C AR E / L I F E C AR E P L AN N I N G
TOPIC 1: PREPARATION & INTERVIEW
COST OF FUTURE CARE/LCP FLOW CHART
Purpose of the Evaluation
Determine Specific Evaluation Questions
Review Medical Records for information on:
Diagnosis, Causality, Prognosis and Medical
Recommendations;
Pre / Post-Accident Level of Function
(Impairment; Activity Limitations;
Participation Restrictions)
Preparation:
Preliminary Assessment Plan: scheduling /
timing; non-standardized tests;
standardized tests, questionnaires.
COST OF FUTURE CARE/LCP FLOW CHART
Intake Interview
Consent and Authorization
Observation of Positional Tolerances (Walk, Sit and Stand)
Review Purpose of
Evaluation
Review Medical and
Social History
Future Plans
Current Complaints /
Symptoms
Perceived Functional
Tolerances
Activities of Daily
Living
Vocational History
and Goals
Avocational Activities Observation of
Cognitive Function
Insight / Awareness Collateral Information Compensatory Tools
/ Strategies
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COST OF FUTURE CARE/LCP FLOW CHART
Reliability of Pain and
Disability Reports
Physical / Cognitive Effort
Findings
Reports vs. Observation of
Function
Pain Evaluation
Non-Organic Signs /
Placebo Tests
Questionnaires
Repetitive Movement
Testing
Insight / Awareness
Heart Rate Analysis
Competitive Test Performance
Hand-Grip Coefficient of
Variation
Bell Curve Analysis
Rapid Exchange Grip
Observation of Clinical
Consistency / Inconsistency
Clinical Observations of CTP
Level of engagement
Evaluation of Cognitive Effort
Physical Cognitive Psycho-Emotional
Questionnaires
COST OF FUTURE CARE/LCP FLOW CHART
ROM Coordination Special Tests
MMT Balance Flexibility
Musculoskeletal Evaluation
Walk, Sit and Stand
Neck and Back
Positioning
Low-Level Work
Tolerance
Stair / Ladder / Other
Positional and Mobility Testing
COST OF FUTURE CARE/LCP FLOW CHART
Reaching, Handling, Fingering and Feeling
Lift, Carry,
Push and
Pull
Grip Work Simulation Circuit
Testing
Metabolic Endurance
Testing
(MET)
Screening
Tests
Cognitive
Component
Tests
Cognitive Performance
Based Tests
Activity Tolerance
/ Durability /
Fatigue
Upper Extremity Coordination
Strength Endurance
Functional Cognitive Standardized/Non-Standardized
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COST OF FUTURE CARE/LCP FLOW CHART
Subjective Data Objective Data
Medical Prognosis
Formulation of Opinion Regarding Future Care Needs
Analysis and Formulation of Opinion
Summary Recommendations Appendices: Table or
Summary of Costs / Data /
Research
Report Writing/Documentation
COST OF FUTURE CARE/LCP FLOW CHART
Purpose of the Evaluation
Determine Specific Evaluation Questions
Review Medical Records for information on:
Diagnosis, Causality, Prognosis and Medical
Recommendations;
Pre / Post-Accident Level of Function
(Impairment; Activity Limitations;
Participation Restrictions)
Preparation:
Preliminary Assessment Plan: scheduling /
timing; non-standardized tests;
standardized tests, questionnaires.
LEARNING OBJECTIVES
Referral Process: What are the steps?
Document Review: What do you ask for, look for, and do with the information?
Preparation: How do you prepare yourself and the client for the assessment?
Interview: What questions do you need to ask and what observations do you need to make?
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THE REFERRAL HAS COME IN…
• Client Details: Date of birth, accident date, home address and phone number.
• Injury Details.• Plaintiff or Defense?• Report or service deadline.• Conflict Check: Have you
worked with the client in a rehabilitation capacity? Is someone else in your practice already retained on the file.
• Confirm rate and estimated costs.
LETTER OF INSTRUCTION
The lawyer should provide you with clear instructions as to:
• What type of assessment they have retained you to conduct;
• The medical documentation they are providing;
• The opinion they are seeking (i.e. future care recommendations and associated costs);
• Instructions as to the required elements of the report as mandated by the courts.
They may also include:
• Statement of assumed facts.
• Special instructions.
TALK TO THE LAWYER
• Clarify referral question (s) and confirm appropriateness of referral.
• Gather relevant client information/concerns.
• Provide some education to the lawyer if appropriate.
• Build relationships.
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DOCUMENT REVIEW
Purpose: • Review opinion regarding the
client’s diagnosis, prognosis, and recommendations relevant to future care.
• Review past treatment history and outcomes.
• Review past medical history and potential functional implications associated with any pre-existing conditions and their long term prognosis, absent the accident.
DOCUMENT REVIEW
What to Request:
• Independent medical opinion/expert opinion (e.g. orthopedic, neurologist, physiatrist, psychiatrist, neuropsychologist, etc.)
• Consult Reports (e.g. including past treatment interventions such as injections, surgeries, etc.)
• Rehabilitation Reports (assessment, progress, and discharge).
What you will also receive that may or may not be helpful:
• Pharmacy records (good to clarify medication usage pre-injury if relevant)
• Handwritten clinical records
• Employment records (can contain information on GRTW attempts, job demands, etc.)
DOCUMENT REVIEW
What to do with these medical opinions?
• Review and summarize opinion on diagnosis, prognosis, and medical recommendations that are relevant to the formulation of your opinion.
• Do not regurgitate the medical opinions in the CFC/LCP Report.
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MARAS V. SEEMORE ENTERTAINMENT
[21] “…I note that there is considerable diversity in the form of the various expert reports. Some are relatively brief and contain an introduction, a summary of facts and assumptions, and the opinion itself. They also contain, in conformity with Rule 11-6(1), the instructions provided by counsel, as well as an index setting out all the documents and other materials which have been reviewed by the expert.”-Maras v. Seemore Entertainment Ltd., 2014 BCSC 1109
MARAS V. SEEMORE ENTERTAINMENT
[22] “Other reports, however, adopt an entirely different approach. They contain lengthy appendices and schedules, including detailed summaries of various interviews which were conducted. In some instances, they also contain voluminous summaries of or comments on the documents and reports which the expert has reviewed. With respect to these latter reports, it will be difficult, and at times impossible, for the trier of fact to differentiate between the assumed facts and the expert’s opinion.” -Maras v. Seemore Entertainment Ltd., 2014 BCSC 1109
MARAS V. SEEMORE ENTERTAINMENT
[29] “…. Generally speaking, appendices to the report should be streamlined, and only include what is necessary for the formulation of the expert’s opinion and/or the facts and assumptions upon which it is based.”
[30] “An appendix containing summaries and comments, to the extent that it does not contain an opinion or underlying facts and assumptions, is no more than a working paper which does not need to be included in the report itself…”-Maras v. Seemore Entertainment Ltd., 2014 BCSC 1109
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DOCUMENT REVIEW
• Identify where there is a range of opinion with respect to diagnosis.
• Identify where there is a range of opinion with respect to prognosis.
• Identify pre-existing medical history and state your assumptions regarding the individual’s pre-injury function.
PREPARATION
• Appointment has been scheduled, including date and time.
• Make sure client has been informed about the length of the appointment and the nature of testing.
• Clarify if any safety issues.
PREPARATION
What to bring:
• Consent forms.
• Questionnaires.
• Testing materials.
• Camera (aka smartphone).
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CONSENT
HEALTHCARE (CONSENT) & CARE FACILITY (ADMISSION) ACT
Consent RightsEvery adult who is capable of giving or refusing consent to health care has:(a) the right to give consent or to refuse consent on any grounds,
including moral or religious grounds, even if the refusal will result in death,
(b) the right to select a particular form of available health care on any grounds, including moral or religious grounds,
(c) the right to revoke consent(d) the right to expect that a decision to give, refuse or revoke
consent will be respected, and(e) the right to be involved to the greatest degree possible in all case
planning and decision making.-Healthcare & Care Facility Act [RSBC] 1996 Chapter 181
HEALTHCARE (CONSENT) & CARE FACILITY (ADMISSION) ACT
Elements of Consent
An adult consents to health care if:
(a) the consent relates to the proposed health care,
(b) the consent is given voluntarily,
(c) the consent is not obtained by fraud or misrepresentation,
(d) the adult is capable of making a decision about whether to give or refuse consent to the proposed health care,
(con’t…)
-Healthcare & Care Facility Act [RSBC] 1996 Chapter 181
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HEALTHCARE (CONSENT) & CARE FACILITY (ADMISSION) ACT
(con’t...)
(e) the health care provider gives the adult the information a reasonable person would require to understand the proposed health care and to make a decision, including information about:
(i) the condition for which the health care is proposed,
(ii) the nature of the proposed health care,
(iii) the risks and benefits of the proposed health care that a reasonable person would expect to be told about, and
(iv) alternative courses of health care, and
(f) the adult has an opportunity to ask questions and receive answers about the proposed health care.-Healthcare & Care Facility Act [RSBC] 1996 Chapter 181
HEALTH CARE CONSENT ACT
Elements of Consent
The following are the elements required for consent to treatment:
1. The consent must relate to the treatment.
2. The consent must be informed.
3. The consent must be given voluntarily.
4. The consent must not be obtained through misrepresentation or fraud.
- Health Care Consent Act, 1996, S.O. 1996, c. 2, Sched. A s.11 (1)
HEALTH CARE CONSENT ACT
Informed consent
A consent to treatment is informed if, before giving it:
(a) the person received the information about the matters… that a reasonable person in the same circumstances would require in order to make a decision about the treatment;
(b) the person received responses to his or her requests for additional information about those matters.
- Health Care Consent Act, 1996, S.O. 1996, c. 2, Sched. A s.11 (2)
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COLLEGE OF OCCUPATIONAL THERAPISTS OF BC
Consent defined:
A contractual agreement whereby a client agrees to submit to certain interventions or procedures to be carried out by the occupational therapist, who in turn agrees to perform the specified intervention or procedures within the limitations and under the conditions set down by both parties.-Practice Guidelines: Obtaining Consent to Occupational Therapy Services, COTBC, March 2008
THE CONSENT IS GIVEN VOLUNTARILY…
What if the assessment is court ordered?
Is it possible for the client to “voluntarily” give consent?
THE CONSENT IS GIVEN VOLUNTARILY…
• [40] “… In the case at bar, in context, the court is not forcing the plaintiff to sign the form of consent. If the plaintiff chooses not to sign the form of consent, the plaintiff’s claim may be struck. It is the plaintiff’s choice.”
• -Gill v. Wal-Mart Corporation, 2017 BCSC 135
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VOLUNTARY VS. COURT ORDERED
Communicating Consent
Consent can be provided orally, in writing, through non-verbal communication, through an interpreter, and/or through alternative and augmentative communication.-Practice Guidelines: Obtaining Consent to Occupational Therapy Services, COTBC, March 2008
VOLUNTARY VS. COURT ORDERED
Documenting Consent
The documentation can take any of the following forms:
i. A note in the client record, and/or;ii. A consent form, that is dated and signed, and/or;
iii. A consent policy/procedure or guideline that is referenced in the client’s record.
-Standards for Consent, COTO, March 2017
CONSENT TO RELEASE INFORMATION
• Consent to release information to the referral source.
• Consent to speak with family members, members of the treatment team, caregivers, etc.
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INTERVIEW
• Accident/Injury History• Current Symptoms• Past and Current
Treatments• Medications• Symptom Management
Strategies• Pre/Post Accident
Medical History• Perceived Functional
Tolerances
PERCEIVED FUNCTIONAL TOLERANCES
• Self-Care
• Homemaking
• Yard Maintenance
• Home Maintenance
• Sitting
• Standing/Walking
• Accessing Low Levels
• Reaching & Handling
• Lifting/Carrying
PERCEIVED FUNCTIONAL TOLERANCES
• Sleep
• Mood
• Cognitive Function
• Community Access
• Transportation
• Finances
• Leisure Activities
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INTERVIEW
• Typical Day:• What time do you get up?
• How do you spend the morning, afternoon, evening?
• What activities to you do outside the home? Do you go outside everyday?
• What time do you go to bed?
• Etc.
• Pre-post accident education or employment history (brief)
FUNCTIONAL & BEHAVIOURAL OBSERVATIONS
• Mobility, sitting tolerance, transfer ability, ability to prepare a drink/snack), etc.
• Awareness, insight, recall, attention, fatigue, etc.
• Involvement of family members in care.
HOMEWORK
• On the next slide, you will find a sample Letter of Instruction. Please identify which questions are within your scope of practice and therefore able to address; and those which are not.
• Prepare a script outlining your consent process when conducting a CFC assessment. What critical elements need to be included in your consent process?
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HOMEWORK
Sample Letter of Instruction:
1. What if any, functional limitations, does Ms. X currently demonstrate?
2. To what extent, if any, are Ms. X’s current functional limitations different from those identified in the Workers Compensation records relating to her pre-existing work related right rotator cuff injury?
3. What are your recommendations in terms of treatments, rehabilitation, modifications, or supports to address or minimize her current functional limitations?
4. For what duration will these treatments and supports be required?
5. What is the prognosis for her pre-existing right rotator cuff injury; and has it changed as a result of the injuries sustained in the motor vehicle accident?
IN PERSON
• Critical elements of a CFC/LCP Report from a legal perspective.
• Formulating facts and assumptions: How to summarize medical opinion in a way that is relevant, readable, and acceptable to the court.
QUESTIONS?
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REFERENCES
• Health Care (Consent) And Care Facility (Admission) Act [RSBC 1996] Chapter 181.
• Health Care Consent Act, 1996, S.O. 1996, Chapter 2, Schedule A.
• Practice Guidelines: Obtaining Consent to Occupational Therapy Services, College of Occupational Therapists of BC, March 2008.
• Standards for Consent, College of Occupational Therapists of Ontario, March 2017.
• Maras v. Seemore Entertainment Ltd., 2014 BCSC 1109.
• Gill v. Wal-Mart Corporation, 2017 BCSC 135.