3/16/2018 topic 1: preparation & interview · questionnaires repetitive movement testing...

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3/16/2018 1 IN COST OF FUTURE CARE / LIFE CARE PLANNING 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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Page 1: 3/16/2018 TOPIC 1: PREPARATION & INTERVIEW · Questionnaires Repetitive Movement Testing Insight / Awareness Heart Rate Analysis ... MARAS V. SEEMORE ENTERTAINMENT ... •-Gill v

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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?

[email protected]

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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.