Rehabilitation and Life Care Planning Symposium Joyce Sharp, OT and Jodilynn Pitcher, DMARehability London, Ontario. May 1, 2014

Transcription

1 Rehabilitation and Life Care Planning Symposium Joyce Sharp, OT and Jodilynn Pitcher, DMARehability London, Ontario May 1, 2014

2 Working within a prescribed form...without the prescription! Ontario Society of Occupational Therapists. (2011). Supporting Occupational Therapy Practice in Ontario s Auto Insurance Sector, Assessment of Attendant Care Needs, Form 1: A Resource for Reflective Practice. Toronto, ON.

3 Remember... To remain focussed on the client s needs in an environment of competing interests. Ontario Society of Occupational Therapists. (2011). Who is asking for the assessment? Who is your client? SABS TORT REALITY

4 SABS vs. Tort SABS: rates are set by FSCO for professional services and the Form 1 is calculated by the number of minutes by the prescribed rate, subject to limits (up to $6, per month or $72, per year) Tort: limitations do not exist and care over and above the SABS can be claimed and recovered. Reality: due to SABS limits family and friends are often forced to provide care without compensation. If a claimant does not have friends or family on which to rely they must hire privately. Private agencies are not bound by fee schedules set out by FSCO and typically have minimum visit charges. Fifteen minutes of basic supervision under the SABS equates to.25 x $8.75/hour = $2.19 per hour. A one hour minimum charge from a private agency for a check in equates to $28.95/hour on average. Depending on geographic location, agencies may even have a 2 or 3 hour minimum charge. Does this change how you calculate attendant care needs?

5 Another dose of reality 24 hour care under the SABS = $72, per year 24 hour care from a private agency at $28.95/hour with statutory holiday pay = $257, per year Is a spouse equivalent to a live-in care giver? Is a livein caregiver a replacement for 24 hour care?

6 Live-in Care Giver a substitute for 24 hour care? Live-in caregiver: prevailing wage $10.86/hour, $11.00/hour as of June 1, 2014 Maximum hours per week 48 hours per week; after 44 hours per week entitled to overtime rate of 1.5 times wage Daily rest period: 11 hours or 8 hours between shifts and successive shifts can total no more than 13 hours Weekly rest period: 24 consecutive hours or 48 consecutive hours/2 consecutive work weeks Meal breaks: 30 minutes if work shift exceeds 5 hours (break may be split in 2) Vacation leave: 2 weeks/year Vacation pay: 4% of wages/year Entitled to take public holidays off work Room and Board deductions: $31.70/week for private room; $53.55/week for meals or $2.55 per meal or $85.25/week for private and board Room must be reasonably furnished and supplied with clean bed linens and towels and be reasonably accessible to proper toilet and wash basin facilities Statutory payroll deductions apply (CPP, EI and Income tax); WSIB coverage is mandatory in Ontario

7 Identify and validate appropriate needs Determine those activities that the client is not able to do for themselves as a result of injuries sustained in the accident as opposed to determining what they have others doing for them Ontario Society of Occupational Therapists. (2011). For example: supervision during bathing Client has accessible washroom (grab bars, non-slip mat etc.) and is observed to perform transfers safely Spouse is always present due to mutual anxiety and fear of a potential fall Supervision is addressing anxiety... is a recommendation indicated on the form 1?

8 Performance of skills and activities: Determine the extent to which the client can perform the skills and activities identified on the Form 1 safely and functionally. Ontario Society of Occupational Therapists. (2011). Objectively identify what assistance, if any, is needed from the present time into the future until another such re-assessment may identify modified needs. Ontario Society of Occupational Therapists. (2011). How does the introduction of assistive devices impact attendant care recommendations and when?

9 Assessing time required predictability and consistency of a client s performance (physical, cognitive, behavioural) must be considered. Ontario Society of Occupational Therapists. (2011)....assessment and/or screening of physical, psychosocial, behavioural, cognitive/perceptual functions lends to comprehensive insight into the client s ability to manage daily living skills independently. Ontario Society of Occupational Therapists. (2011). Consider that assessments are artificial and behavioural and cognitive considerations are vastly different in day to day life versus in an assessment situation. How do you capture this in one assessment?

10 Lifelines and attendant care lifeline is an easy-to-use personal response service that lets you summon help any time of the day or night - even if you can't speak. All you have to do is press your Personal Help Button, worn on a wristband or pendant, and a trained Personal Response Associate will ensure you get help fast we help thousands of seniors and disabled people live with greater independence and dignity in their own homes. dedicated to helping seniors, the physically challenged, and patients with medical conditions live confidently and safely at home.

11 Is a lifeline appropriate? Designed for those at risk of falls Will it reduce or eliminate the need for attendant care for those with severe physical or cognitive impairments? Is it appropriate for the cognitively challenged client? is cost savings a motivator? Does it recreate the person s pre-accident ability to respond in an emergency?

12 Case law example Morrison v. Greig [2007] O.J. No. 225 at par.125 Defence argued that catastrophic spinal cord injured claimant would benefit from a lifeline over attendant care. Justice Glass stated: For example if there were a fire and it was going to take a personal care worker a half an hour to come to his residence the Plaintiff might die in the meantime. This Plaintiff is not one who only needs a nanny to pick up after him. He needs someone who can be there right away and some one who understands the limitations of a spinal cord injured person so that he can be assisted properly.

13 Marcoccia v. Gill, 2007 CanLII (ON SC) Mr. Marcoccia was 20 years old when he suffered frontal and temporal lobe impairments, leftsided hemi-paresis in a motor vehicle accident. He displayed prominent disinhibition, impulsivity and lack of insight into his own impairments. Plaintiff Counsel argued that this left him unsuitable for assisted group home living and that he required instead 24-hour day/7-day week care for the duration of his lifetime (8 hours/day of care from a rehabilitation support worker and 16 hours/day from an attendant care provider). The defence presented scenarios for Mr. Marcoccia s future care at trial including that he be placed in a group home and that he could use a Lifeline to call for assistance if needed, reducing the amount of hourly wage attendant care required.

14 Medical expert opinion Dr. Scherer In his opinion, the neuropsychological and motor deficits are permanent and severe. There will be no further recovery, as such, at this point, many years after the accident. He needs attention not just on a daily but on an hourly basis. Without cueing, daily tasks won't get done. As well, he will be unsuccessful in problem solving, planning activities and following through. In cross examination, Dr. Scherer admitted that there is nothing in his reports specifically pointing to a concern that Robert would be unable to look after his own personal safety in the home or in the community. He also admitted that, although Roberts deficits are observed and expected in people with brain injury, they are all behavioral and psycho emotional problems, problems that people can have without brain injury.

15 People who are limited in their ability to self-monitor have difficulty implementing strategies to assist with their deficits; Robert is one of those. These people have difficulty with adapting to assistive devices such as Palm pilots, diaries or other memory aids. They do not have the insight they need and lack the anticipatory awareness necessary to make them willing and able to plan ahead. They are too distracted by immediate gratification. The problem with Robert is that all of his impairments occur in the context of normal intelligence. He can learn but is not able to use whatever he learns in an organized and focused fashion.

16 Medical expert opinion Dr. Voorneveld Robert needs a rehabilitation support worker with him, someone who is trained to prompt and queue, to organize, to reason with him and to problem solve and that person should be with Robert eight hours each day. During Robert s remaining waking hours, he is still at risk for flying into fits of rage, to inappropriate behavior and safety problems. Accordingly, he needs attendant care and at a level involving someone with some understanding of his needs and limitations. Even while sleeping, a basic attendant care person should be with him, in order to respond to any potential emergency situations which arise and which Robert would not be able to deal with effectively. A shared care or group home situation is not appropriate for Robert. He would not be able to see other people's boundaries and he would not last in that environment.

17 Assistive devices are generally not useful for Robert because of his inability to follow through with their use. Asked about an intensive rehabilitation period followed by three hours per day of attendant care as an option going forward [the defence scenario], she feels that Robert would not cooperate and that reducing his hours of attendant care would be counterproductive. Robert has plateaued and needs ongoing support. She said that she feels it is important that there be someone present for Robert at all times. She is well aware of services such as Life Line that Robert could call in an emergency situation. He is capable of pushing a button but this doctor says much depends on his perception of danger. There are so many unpredictable situations that he may not have the judgment necessary to make appropriate decisions, including the decision to call the lifeline facility.

18 This doctor maintains that 8 hours per day of attendant care with a rehabilitation support worker together with 16 hours of care by an attendant care worker is appropriate and this has been her view from the outset of her involvement with this case. This doctor's recommendations stand even though, in cross examination, she admits knowing that Robert has not had attendant care from a rehabilitation support worker ever until now at the rate of 8 hours per day for seven days each week. Jury award: $15,650,182 in damages including $13,953,064 for future care, [2007] O.J. No. 1333

19 Rehabilitation Therapy vs. Attendant Care Med Rehab Benefit vs. Attendant Care Benefit $50 - $60/hour vs. $23 - $30/hour What are the roles and responsibilities of the RSW vs. PSW and are they interchangeable? Is an RSW for specific task /community integration that may require only a couple of hours a week and the remainder be accomplished by a PSW? What are the pros and cons for this?

20 Case Study #1 24 year old male with C5 quadriplegia x 2 years: Lives alone; no partner; no family (no one home through the night) At risk for UTI (due to practice of not performing IC s and using condom catheter only); at risk for skin breakdown because sleeps on regular mattress. No UTI s or skin issues for at least two years.

21 Reflection 24 hour AACN does not pay for 24 hour AACN Does he qualify for 24 hour AACN with history of zero complications and zero need for help through the night? Is access to help by phone enough? What about AD and potential for not being able to call for help? How does one quantify availability of help? How do you cost that if you have to hire someone? Knowledge of SCI, particularly high level SCI injuries predicts periods of bedrest for bedsores

22 Case Study #2 Elderly bariatric paraplegic Cannot transfer independently; uses a ceiling mount lift with help of two people due to her size. Frequent urinary infections, skin issues. Able to exit home with help of one person only when already up in power or manual wheelchair.

23 Points for Reflection Cost for two attendants Reduce to one attendant when up; How does one predict when she will be up consistently?

24 Case Study #3 45 year old female with post concussive disorder and chronic pain; stress, anxiety, depression, passenger anxiety Psychological Associate (supported by Psychologist) recommends 24 hour supervision secondary to risk of suicide. Eventually, recommendation for 24 hour supervision is lifted but there is no change in observable behaviour or the degree of guidance, support, supervision provided and required. Eventually, client is left alone for 4 hour intervals over a period of 6 months. A system is put into place whereby she gets up from bed two hours into her husband s absence then has clearly, previously determined activities she follows for the second two hours (or she just sits staring out the window)

25 Points for Reflection 24 hour supervision clearly recommended and supported. How long is it continued after recommendation lifted with no change in observable behaviour? What if family tells you that the client does nothing unless directed by family member? Do you include time just for cues? How can you predict when they are? Do you deduct time based on history of several months while this system worked?

26 Case Study #4 30 year old male with severe ABI Strictly structured routine in place in the client s home where he lives alone, in a rural and isolated location. Brother checks on client directly each morning, reviews the day s activity. Brother may call or visit later but reviews days events, bills, appointments, plans, etc., sets up the plan for the next day. Brother available through the day by phone; client is able to make phone calls when needed. Help is needed whenever the planned and structured routine is interrupted by an unplanned event (e.g. unexpected visitor, unexpected bill, break down of equipment or appliance, damage to house.)

27 Case Study #4 Continued Without daily review and planning, the client becomes quickly disoriented, agitated, confused, distressed, anxious. Client is paranoid about the activities of distant neighbours and has discussed what appear to be delusional beliefs (none that would indicate harm to self or others). Client has never called 911 but has consistently indicated when it is appropriate to do so and can operate a phone and cell phone.

28 Points for Reflection 24 hour care? Recommend actual time spent with client and for phone calls? if hiring privately; cannot hire for short intervals and phone checks are not provided How do you quantify phone check ins?

29 Case Study #5 Elderly individual with subtle signs of Alzheimer s involved in MVA (while on scooter) resulting in concussion and full exacerbation of Alzheimers/concussion symptoms. Client was able to walk to and from the local mall independently and was able to monitor blood sugar and inject insulin accurately prior to the MVA Currently, the client is disoriented consistently, does not pay attention to time, has no recollection of when and how to monitor blood sugar or dose insulin. Will not accept guidance or caution from wife. Wife is elderly and cannot provide significant assistance nor contribute at all to physical requirements for assistance. Cannot comply with any new procedures. Consistently tries to take out scooter.

30 Points for Reflection 24 hour supervision? Pre-existing dementia Publically funded supports in place