Assessment in Medical Setting

1. Assessment in Medical Setting General characteristics of the medical setting Diagnostics in hospital setting

2. Medical Behavioral Systems/ social

3. General Characteristics of the Medical Model

4. General Characteristics of the Medical Model • Physician directed • Team oriented • Highly regulated • Accreditation agencies (JCAHO, CARF) • Funding agencies (CMS) • Influenced by third party pay • Focus on “Best Practice”

5. Once upon a time……….. • Hospitals were non-profit, faith based • You went to the hospital when you were sick, you stayed until you were well • Your treatment depended solely on the practice of your physician---and you didn’t ask questions! • Your insurance company paid the bill (if you had insurance) • There were few SLP jobs in hospitals

6. Today…. • You may go to a publicly held, corporate hospital trying to make a profit to satisfy investors • You progress through the continuum of care • Your care is scripted by a “care path” that outlines a best practice model • Your insurance company has negotiated a rate for your care • Your “outcome” is tracked and reported for quality assurance purposes • You are an empowered consumer!!

7. Medical Continuum of Care

9. DRG: • Primarily for acute-care hospital stays • Based on specific Dx codes (International Classification of Disease –ICD 10, WHO, 2003), e.g. • Brain injury • Concussion • TIA • “Cerebral infarction due to thrombosis of cerebral arteries….” • RUG: Requires complex assessment process: “minimum data set” • Primarily for subacute care centers (nursing homes and home health agencies • Determined based on • Specific diagnoses (e.g. hemiplegia) • Unique symptoms (e.g. wandering, fever) • Services required (oxygen therapy; speech therapy four times per week)

10. Why the changes????? • Government funding of healthcare • Corporate need to contain healthcare costs in a global economy • Focus on safe, effective and efficient care

11. Impact of Managed Care

12. Impact of Managed Care • Third-party payers (e.g., Medicare, corporations)…. • pay fixed price for services incentive for service provider to keep down costs

13. Impact of Managed Care (cont.) • Positive impact • Efficient providers • Negative impact • Compromised quality of care from providers • Comprehensive eval replaced by selective testing • Rushed evaluation

14. Impact of Managed Care (cont.) • Practical impact • Increased need for • Screening tests • Short versions with norms (e.g. Boston naming) • Subtests with norms (e.g. BDAE) “Pruning may lop off too much” • Measures of functional performance (e.g. FIM)

15. Assessment Goals Vary by Assessment SettingThink: What is role of this setting in the overall continuum of care? How will that affect diagnostic goals?

16. Medical Continuum of Care

17. Different Settings, Different Assessment Goals • Intensive care unit: 2 or 3 days • Assessment to assist in differential diagnosis • On-going assessment using sensitive meansures to monitor for: • Changes in medial status • Need for additional medical intervention

18. Different Settings, Different Assessment Goals • Acute care: 3-7 days • Efficient methods of differential diagnosis • Short frequent visits to assess • Maximum performance • Performance variability • Why: Goal is to make recommendations for D/C planning

19. Different Settings, Different Assessment Goals • Inpatient rehabilitation and rehabilitation in skilled nursing facilities • 10-28 days in IP rehab to improve functional abilities; 10-28 days in SNF, to improve patient’s medical status and Fx’l abilities • De-emphasis on assessment • Only Tx time may be reimbursed • Time is limited • On-going functional assessment is incorporate into Tx session • Why? To document outcomes directly linked to therapy

20. Different Settings, Different Assessment Goals • Long-term care: Goal is to facilitiate quality of life • Rehab services are limited • Screening assessments may be used to • monitor all residents’ maintenance of functional skills • Provide baseline for resident who suffer an acute medical event, such as a stroke, while in LTC • Intermittent assessment in conversational group settings, designed to facilitate quality of life.

21. Different Settings, Different Assessment Goals • Home health (14-30 days, although some people retain skilled home nursing care for longer durations)…and outpatient (4-12 weeks, or potentially longer if patient shows functional gains and has financial resources) • Assessment will be designed to document improvement in functional communication skills • “Functionality” will be strongly indexed to the client’s immediate personal and environmental context of communication

22. So, do you see how goals of assessment may transform/change across the continuum of care? Let’s compare this change back to our models of assessment

23. Medical Behavioral Systems/ social

24. Practical Considerations

25. Once Assessment Goals Are Set, What Are Sources of Information for the Process of Information-Gathering? 1. Consultation request/referral 2. History 3. Examination

26. 1: Consultation request/referral Example: “55 y/o R-H M 1 day s/p recent L MCA CVA, RUE, RLE weakn. Globally aphasic… …Hx DM, HTN… …Pls eval pt’s sp & lang & make recs.”

27. 2: History Doctor’s orders: “…Hx DM, HTN…” Doctor’s orders to other disciplines Medical record: (p. 99 of readings) Physical and neurological exam Progress notes : (p. 105 of readings) Lab reports Interview of patient and family

28. Consciously consider each piece of information…. • In referral/consulation request • In location of patient, re: goals of Dx • Presence of disorder • Severity of disorder • Nature of disorder • Prognosis for benefits of Tx • Patient demographics • Medical diagnosis • Services requested

29. Consciously consider each piece of information (cont.) • In medical record • In physical/nueorological examination • In doctor’s orders • In progress notes • In lab reports

30. 3: Examination Interview with family Interview with patient Testing and examination

31. Interviewing patient and family • Purposes (Equally important!) • Information gathering • Getting interpersonal relationship off to good start

32. Interviewing patient and family • Steps/principles of interview/assessment • What they are told before testing

33. ….and for testing and examination…

34. If your goal is differential diagnosis, what are you looking for? Symptom Departure from normal in Fx, appearance, sensation Subjective, experienced by patient Sign Abnormality that is observable (by you, by M.D….) Objective Syndrome Constellation of signs and symptoms

35. Scientific method  Clinical method Iterative Process ! Consciously consider each piece of info as it is received

36. If your goal is documenting patient progress in treatment, how do you do this? Think back to what diagnostic procedures are used for tracking treatment progress….

37. If your goal is to screen and monitor, how do you do this? What kind of assessment procedure is typically used in screening?

38. If your goal is to assess for functionality, how would you design this? What kind of assessment procedure is typically used in for assessing functionality in everyday contexts?