TOPIC 1: PREPARATION & INTERVIEW IN COST OF FUTURE CARE / LIFE CARE PLANNING 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 Current Complaints / Symptoms Vocational History and Goals Review Medical and Social History Perceived Functional Tolerances Avocational Activities Future Plans Activities of Daily Living Observation of Cognitive Function Insight / Awareness Collateral Information Compensatory Tools / Strategies
COST OF FUTURE CARE/LCP FLOW CHART Reliability of Pain and Physical / Cognitive Effort Disability Reports Findings Reports vs. Observation Heart Rate Analysis of Function Competitive Test Pain Evaluation Performance Non-Organic Signs / Hand-Grip Coefficient of Placebo Tests Variation Questionnaires Bell Curve Analysis Repetitive Movement Rapid Exchange Grip Testing Observation of Clinical Insight / Awareness Consistency / Inconsistency Clinical Observations of CTP Level of engagement Evaluation of Cognitive Effort Questionnaires Physical Cognitive Psycho-Emotional COST OF FUTURE CARE/LCP FLOW CHART Musculoskeletal Evaluation ROM Coordination Special Tests MMT Balance Flexibility Positional and Mobility Testing Walk, Sit and Stand Neck and Back Positioning Low-Level Work Tolerance Stair / Ladder / Other COST OF FUTURE CARE/LCP FLOW CHART Upper Extremity Coordination Lift, Carry, Push and Pull Strength Reaching, Handling, Fingering and Feeling Grip Functional Cognitive Work Simulation Circuit Testing Endurance Metabolic Endurance Testing (MET) Standardized/Non-Standardized Screening Tests Cognitive Component Tests Cognitive Performance Based Tests Activity Tolerance / Durability / Fatigue
COST OF FUTURE CARE/LCP FLOW CHART Analysis and Formulation of Opinion Subjective Data Objective Data Medical Prognosis Formulation of Opinion Regarding Future Care Needs Report Writing/Documentation Summary Recommendations Appendices: Table or Summary of Costs / Data / Research 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?
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.
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.
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
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. What to bring: Consent forms. Questionnaires. Testing materials. Camera (aka smartphone). PREPARATION
CONSENT HEALTHCARE (CONSENT) & CARE FACILITY (ADMISSION) ACT Consent Rights Every 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, -Healthcare & Care Facility Act [RSBC] 1996 Chapter 181 (con t )
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)
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 limitation 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
VOLUNTARY VS. COURT ORDERED Communicating Consent Consent can be provided orally, in writing, through nonverbal 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.
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
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?
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? mathesoncfc@gmail.com
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.