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Specialised Spinal Cord
Injury Reassessment
Services
Operational Guidelines
September 2009
This is a living document and will be updated as required
Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines
Contents
Introduction ............................................................................................. 1
Who can access the service ........................................................................ 1
Service philosophy .................................................................................... 1
Service commencement ............................................................................ 1
Geographical boundary .............................................................................. 1
Service provision principles ........................................................................ 2
Physicians employed by the service ............................................................ 3
Service Requirements .............................................................................. 3
Key elements ........................................................................................... 3
Reassessments ......................................................................................... 4
Remote Contact Screening Reassessments .............................................. 4
Service inclusions ..................................................................................... 4
Location .................................................................................................. 5
Frequency ................................................................................................ 5
When prior approval is required .................................................................. 5
Completion .............................................................................................. 5
Outreach, Inpatient, and Outpatient Reassessments ............................... 6
Service inclusions ..................................................................................... 6
Location .................................................................................................. 7
Frequency ................................................................................................ 7
Prior approval .......................................................................................... 8
Completion .............................................................................................. 8
Specialist Initial and Follow-up Assessments ........................................... 8
Outreach Clinic Reassessments ................................................................ 8
Geographical locations............................................................................... 8
Community linkages .................................................................................. 9
Travel to outreach clinic reassessments ....................................................... 9
Calculating travel time and costs .............................................................. 10
Payment for Non-Attendance by Clients ................................................. 11
Resources for Services ........................................................................... 11
Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines
Exceptions .............................................................................................. 12
Occurrence of an exception ...................................................................... 12
Exception report ..................................................................................... 12
Outcome Measurement .......................................................................... 12
Service Monitoring and Clinical Review .................................................. 13
Appendices ............................................................................................. 14
Appendix 1: Remote Contact Screening Reassessment Questionnaire ............ 14
Appendix 2: The Spinal Evaluation and Assessment Report (SEAR) ............... 16
Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines
Introduction
The following information is designed to help you interpret the Specialised Spinal
Cord Injury Reassessment Services agreement. These operational guidelines are
only related to the reassessment service, a separate guideline is in place for the
Specialised Spinal Cord Injury Active Rehabilitation Services agreement.
Who can access the service
This service is for clients with a spinal cord injury who have completed their
inpatient rehabilitation and have returned to active participation in their
community. Reassessment services are planned and implemented to specifically
prevent or minimise the impact of secondary complications, by giving clients
access to regular and routine reassessment of their health, function, and
wellbeing status.
Service philosophy
The central philosophy of the service is that with targeted support and access to
ongoing education, people with spinal cord injuries can prevent the development
of secondary disability and maintain their health and wellbeing.
Service commencement
Reassessment services begin when a client is discharged from Specialised Spinal
Cord Injury Active Rehabilitation services. The details of the proposed first
reassessment will have been provided to ACC client service staff in the discharge
report. Reassessments may be undertaken:

A minimum of once and a maximum of twice within the first two years of
discharge from the spinal unit, and

Then once in every three-year cycle, or

At any time that the vendor or the client’s GP make a written
recommendation to ACC and ACC approves the request for reassessment.
Remote reassessments will be undertaken annually unless there is a clinical
decision to reduce the frequency to every two years. No prior approval is
required for routine scheduled reassessments.
Geographical boundary
New Zealand’s two spinal units provide services to clients with spinal cord injury
within defined geographical boundaries. The boundary runs diagonally across the
North Island between Taranaki and Gisborne.

The Auckland Spinal Rehabilitation Unit provides services for the following
areas: Gisborne, Taupo, Rotorua, Hamilton and north of these centres.
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
The Burwood Spinal unit in Christchurch provides services for the following
areas: Hasting, Napier, Palmerston North, New Plymouth and south of
these centres.
Providing reassessment services to clients outside a unit’s geographical
boundary
In some circumstances the Spinal Units may provide services to clients who live
outside of their geographical boundary. For example it may be easier for a client
living in Wairoa to attend an Outreach Clinic in Gisborne rather than Hastings.
Clients who have received Active Rehabilitation services from one Spinal Unit but
return to live in the other Spinal Unit’s geographical area may attend the first
reassessment from the Unit that provided the Active Rehabilitation. All
subsequent reassessments should be provided by the Spinal Unit that is
responsible for the geographical area that the client lives in.
In all cases the vendor must obtain approval from ACC client service staff.
Service provision principles
Delivering this service incorporates current practice rehabilitation principles to
meet the specific needs of this population group. Specifically, the service delivery
will focus on the following principles.
1. Service model
The service is based on the principles implicit in the World Health Organisation
International Classification of Functioning, Disability and Health model. The
model looks at:

Body structure and the function or impairment of organs, and

The person’s activity and any limitations to their activity,

The person’s participation in society and any restrictions to that.
2. Client centred services
These must:

Be delivered in a supportive manner that respects the dignity, rights,
rehabilitation needs, and cultural values of the client.

Improve the client’s ability to understand and self-manage their injury via
an tailored rehabilitation plan based on bio-psycho-social models.

Facilitate all people involved in the client’s rehabilitation (family/whanau,
community providers, employers, etc) to work in a partnership approach.

Restore a client’s sense of control through self-management (as far as
practicable), achieving increased function, realistic goal-setting and
improved coping strategies.

Achieve timely outcomes in a planned and cost-effective manner.

Be planned and provided to meet the needs of clients living in remote
geographical locations.
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3. Management and organisation of services
This requires:

An effective management structure with clear lines of accountability and
responsibility.

Adequate and appropriate resources and administrative support.

Timely planning of service provision that involves travel and
accommodation to minimise cost.

Access to, and use of, information technology to maximise communication
and decision-making.
4. Integration between primary, secondary, and tertiary services
This requires:

Effective communication between all levels of care, all specialities, and
professional groups.

An awareness of the reassessment services provided by the spinal unit.

The spinal unit to network and develop informal educational opportunities
for community teams to provide increasing support to Spinal Cord Injury
(SCI) clients in the community setting.
Physicians employed by the service
Physicians employed by the service will preferably be Fellows of the Australasian
Faculty of Rehabilitation Medicine.
“Oversight” is needed for medical practitioners who may work in a rehabilitation
unit but do not have a vocational registration in Internal Medicine or
Rehabilitation Medicine.
If the vendor’s rehabilitation physician is not available for any reason, the vendor
may nominate an alternate member of the rehabilitation team to determine client
eligibility. If the alternate member chosen will have a significant impact on
service provision, the vendor must provide written notice to the Spinal Services
Programme Manager.
Service Requirements
Key elements
There are four key elements of spinal injury reassessment services:
1. Comprehensive evaluation (reassessment) of a client’s health and
functioning
2. Specialist initial and follow-up assessments
3. Minor procedures
4. Timely provision of reporting on a client’s outcomes to ACC.
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Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines
Reassessments
All reassessments include:

History taking and/or examination of the client by appropriately qualified
personnel

An interdisciplinary team consisting of a spinal specialist and at least two
other members which may include allied health and nursing to assess
aspects of the client’s health that are directly relevant to the most
appropriate treatment options(s).

Discussion between the client and the assessor on appropriate treatment
options including conservative or non-surgical treatment. Non-surgical
options should be promoted, if they are as effective or more effective than
surgical options, unless these have already been tried and did not give the
desired rehabilitation outcomes for ACC or the client.

All administration normally required during the reassessment services.
This includes recording service outcomes in clinical notes and /or through
internal information systems to allow the vendor to evaluate the service.

Appropriate documentation such as the Spinal Evaluation and Assessment
Report (SEAR) and any associated (ancillary) reports needed to support
the referral of the client on to surgical services or back to the original
referrer if that was the client’s GP.

Due consideration of the morbidity foci relevant to each client, eg level of
mobility and muscle function, skin, renal and urinary status, mega-colon,
chest care, medications, employment, recreation and community
participation, substance abuse, and psychosocial status.
Remote Contact Screening Reassessments
A remote contact screening reassessment is a structured interview designed to
elicit specific information from the client on their current health, wellbeing, and
functional status.
Service inclusions
The remote contact screening reassessment includes:

Review of the client’s records on database

Review of the clients clinical records

Decision on mode of communication

Coding and sending out the remote contact form

Obtaining the client’s current contact details from client service staff

Contacting the client to interview them with a predefined series of
questions designed to ascertain their current medical, functional, and
psychosocial outcome status in accordance with Appendix 1, pg 13
Note:
ACC may at times, amend the Appendix 1 list without the need for a
variation to the agreement, in consultation with the vendor who may wish
to ask additional appropriate questions.
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
Follow-up actions after the contact

Updating the vendor’s clinical records, as to the client’s medical, functional
and psychosocial outcome status

Determining whether a more comprehensive reassessment should be
conducted either at an outpatient or outreach clinic

All administrative and ancillary matters associated with the remote contact
screening reassessment interview

Any advice necessary for client education, family/whanau support, and
community integration

Providing a recommendations report to ACC detailing the client’s medical,
functional, and psychosocial outcome status and whether or not referral
for a more detailed reassessment is indicated

Updating the database and/or patient management system

Submitting an annual database report to ACC.
Location
Remote contact screening reassessments may be carried out as a face-to-face
meeting or from a remote location using other appropriate means of
communication, eg telephone, video-conference, email, letter, facsimile, etc.
Frequency
Each client should be reassessed annually. However, a clinical decision can be
made to complete one every two years which must be agreed with the client and
communicated to ACC.
When prior approval is required
The vendor does not require prior approval for scheduled reassessments.
However, they will need to obtain a purchase order number from ACC via prior
notification.
Exception
Prior approval from ACC is required when a non-scheduled reassessment is
recommended by the vendor or the client’s general practitioner.
Completion
At the end of the remote contact screening assessment the vendor will update the
client’s clinical records and forward a completed recommendations report to ACC
client service staff and the client’s GP.
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Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines
Outreach, Inpatient, and Outpatient Reassessments
The majority of clients with a spinal cord injury (SCI) will return to live in their
local communities when they are discharged from the spinal unit. Reassessments
are conducted to help clients maintain their level of rehabilitation and reduce the
incidence of complications associated with spinal cord injuries.
Reassessments are a comprehensive assessment of the client’s current health,
function, and wellbeing status. Clients are seen by the interdisciplinary team
either in the spinal unit inpatient or outpatient facility, or at an outreach clinic.
Service inclusions
A reassessment includes:

A structured clinical interview including the matters set out in the remote
contact screening questionnaire in Appendix 1, pg 13.

A general medical examination including:

-
A general physical examination
-
Wheelchair and equipment checks to ensure these are in working order
and continue to meet the client’s injury related needs
-
Urinaylsis
-
Spirometry
-
Blood tests (eg FBC, ESR, biochemistry) where indicated
-
Renal ultrasound
-
X-rays (‘KUB’).
Special investigations, if required, that may cover all or any of the
following:
-
Advanced urodynamics
-
Advanced renal/urological assessment
-
Lung function tests other than spirometry
-
Any specialised blood tests
-
Advanced orthopaedic assessment
-
Plastic surgical assessment
-
Neurological and neurosurgical assessment
-
Urological assessment
-
Sexuality and fertility assessment
-
Clinical psychological evaluation
-
Psychiatric evaluation.

Therapeutic pharmacology and administrative matters associated with
pharmaceutical prescriptions as required.

Telephone advice to the client’s hospital staff and general practitioner as
required.

All consumables associated with the reassessment.

Access to diagnostic radiology including up to two CT or MRI examinations.
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Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines
Note:
Referral to Low Tech and/or High Tech Radiology Services is the
responsibility of the vendor. The Radiology Provider will invoice ACC
directly for services. Clients are not required to pay a surcharge for
diagnostic radiology or ultrasound procedures. If a specialist
considers that more than two CT or MRI scans are clinically desirable, the
vendor must apply to ACC for approval of these scans. If approved, the
vendor will arrange for the CT or MRI scan and take into account the
results of this scan in the report produced at the end of the reassessment.

Access to diagnostic pathology.

Providing a Spinal Evaluation and Assessment Report (SEAR) to ACC
containing the information described in Appendix 2, pg 15.

Determining whether any additional advanced reassessment modalities are
required and, if advanced reassessment services or surgical treatment is
recommended, describing this in an Ancillary Report to the SEAR.

Providing a copy of the SEAR and any Ancillary Reports to the client’s
general practitioner.
Notes:

If ‘Wheelchair and Seating’ or ‘Transport for Independence’ assessments
are indicated these will provided under the appropriate contract with ACC
and with prior approval from ACC. These services are not paid for under
this agreement.

If Radiology (High and Low Tech) Services are indicated, these will be
provided under the appropriate contract or paid for under regulation.
Location
Reassessments may be undertaken at the spinal unit inpatient or outpatient
facility. An inpatient reassessment is a 3-day reassessment where the client is
admitted back into the spinal unit from the community. An outpatient
reassessment usually takes place at the spinal unit’s outpatient facility and is
conducted by the interdisciplinary team, ie the spinal specialist, allied health, and
registered nurse.
Frequency
Reassessments may be undertaken:

A minimum of once and a maximum of twice within the first 2 years of the
client’s discharge from the initial rehabilitation phase.

In a 3-year cycle, eg 5th, 8th and 11th year, after the first 2 years postdischarge.

At any other time where reassessment is recommended by the vendor or a
community provider (eg GP), and ACC has given prior approval for this.
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Prior approval
Prior approval is not required. However, prior notification is needed to obtain a
purchase order and to ensure that ACC is able to co-ordinate any ancillary
services, eg travel needed for the client to attend a reassessment appointment.
Prior notification should be sent at least 10 working days before the reassessment
appointment.
Completion
After the reassessment the vendor will update the client’s clinical records and
forward a completed SEAR report to ACC client service staff and the client’s GP.
Specialist Initial and Follow-up Assessments
Specialist initial assessment
Specialist initial assessments are carried out for a client when:

The client has a spinal cord injury and the specialist needs to be involved
in making recommendation(s) for treatment and/or treatment options

The client needs a more complex level of investigation than would usually
be needed for other reassessments.
Specialist follow-up assessment
Specialist follow-up assessments are subsequent assessments where the primary
purpose of the appointment is to discuss the results of tests with the client and
explore the client’s treatment and rehabilitation options. The consultation must
take place on a different day from the initial assessment/reassessment.
Outreach Clinic Reassessments
Geographical locations
Reassessment outreach clinics are held in regional centres remote from the spinal
unit, and give clients the opportunity to receive reassessment services in, or
closer to, their home locations.
From time to time the vendor may add or remove a clinic location. To do this,
they must give the Programme Manager one month’s notice and provide reasons
for the change in service coverage.
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If a clinic is to be added the vendor must send the Programme Manager the:

Planned date of the first services at outreach clinic

Facility location

Geographical region

Frequency of clinics per annum

Name of key community providers/DHB that the vendor has key linkages
with.
Community linkages
Prior to the planned reassessment outreach clinic a designated member of the
interdisciplinary team will ensure effective and timely communication between the
vendor, ACC client service staff, and local community teams to ensure that the
following is available for each client who will be seen at the clinic:

Most recent Social Rehabilitation assessment, if required.
Note:
ACC client service staff will make this available to the vendor before the
outreach clinic opens.

Clinical summary from the GP, if required.

Care and rehabilitation plan from the community teams, if required.

Any additional document from significant others involved in service
delivery to the client.
Members of the outreach clinic team will:

Provide informal education for community teams that will help these
providers support clients in their own communities.

Work towards training community teams to help with outreach clinic
assessments, but will remain responsible for providing specialist oversight
to the community teams.
Travel to outreach clinic reassessments
ACC will pay the vendor’s costs for travelling to reassessment outreach clinics to
provide services. Travel costs may include one or more of the following:

Air travel

Car rental

Taxi costs

Private car

Accommodation

Allied health staff travel time

Medical staff travel time.
ACC will pay for the travel costs for up to the number of staff identified in the
service specification.
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When ACC has asked the vendor to conduct a reassessment outreach clinic in an
area that is not the vendor’s usual location then ACC will pay actual and
reasonable costs for:

Overnight accommodation when necessary

Air travel (the vendor will arrange travel as far as possible in advance to
ensure the most economical airfares are purchased)

Car rental

Vendor’s taxi costs when required

Private car costs paid at 62 cents per km (when private car costs are
claimed for travel to outreach clinic locations, ACC will not also pay air
travel, car rental, taxi costs, or travel by bus or train fares)

Travel by bus or train

Other travel costs associated with travel to an outreach clinic location

Travel time (ACC will pay for the time taken for the vendor’s staff to travel
to outreach clinics at the price listed in clause 15 of the service schedule.
Calculating travel time and costs
Calculating travel time
ACC will pay for travel time to outreach clinics via the most direct route. Costs
are calculated as follows:


TRAVT5 - Allied health price
-
multiplied by the time spent travelling
-
multiplied by the number of allied health staff travelling (3 maximum)
-
divided by the number of spinal cord injury clients assessed at the
clinic (including both ACC and Ministry of Health clients).
TRAVT5 - Medical specialist price
-
multiplied by the time spent travelling
-
divided by the number of spinal cord injury clients assessed at the
clinic (including both ACC and Ministry of Health clients).
Calculating travel costs
The vendor will calculate travel costs for each outreach clinic by dividing the total
travel costs (air travel, car rental, taxi costs, private car, accommodation, and
travel time), and calculated in accordance with the service schedule by the
number of spinal cord injury clients (both ACC and Ministry of Heath clients)
assessed by the vendor’s staff at the outreach clinic.
The vendor will invoice the resulting cost regarding each client in accordance with
this agreement, and will keep records of all invoices and receipts for all travel
costs claimed. These must be provided to ACC on request.
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Payment for Non-Attendance by Clients
Client non-attendance at reassessment outpatient clinics
If a client fails to notify a vendor that they cannot attend a scheduled
reassessment at an outpatient clinic, at least 24 hours beforehand, ACC will pay
the vendor a non-attendance fee of 40% of the outpatient reassessment price
listed in clause 15 of the service schedule.
Client non-attendance at reassessment outreach clinics
If a client fails to notify a vendor that they cannot attend a scheduled
reassessment at an outreach clinic, at least 48 hours beforehand, ACC will pay
the vendor a non-attendance fee of 60% of the outreach reassessment price
listed in clause 15 of the service schedule.
The vendor may only claim one non-attendance payment per client per episode of
care. ACC will only make payment when the following criteria are met:

ACC has required the client to attend a reassessment, or

The vendor has initiated a routine reassessment, and

The client has failed to notify the vendor of their non-attendance within
the relevant timeframe above, and

The vendor has informed the ACC client service staff of the nonattendance within 48 hours of the non-attendance, and

The vendor provided evidence to ACC on request of any contact made by
phone, fax, or email with the client and ACC client service staff at least 48
hours before the appointment to confirm attendance.
Resources for Services
The vendor must have:

Staff who are appropriately qualified to assess the client’s need for
reassessment services, and carry out the services under the agreement.

Specialist clinical supervision for any junior medical staff, or medical staff
in training who are involved in reassessment service delivery.

Access to a nursing team that is led by registered nurses with specialised
training or experience in the relevant speciality.

Technical and allied health staff with appropriate qualifications and
registrations.

Adequate back up facilities and staffing arrangements for an
interdisciplinary approach to reassessment services.

Access to a sufficient range of diagnostic and assessment services that will
help the interdisciplinary team reach accurate diagnoses and plan
reassessment and treatment accordingly.
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Exceptions
Occurrence of an exception
An “exception” is when an incident has occurred that:

Is clearly outside of accepted rehabilitation practices. The occurrence may
be notified by the client or another person, eg staff member, member of
the public or family, or

Is of an unacceptable risk to the safety and security of the client or
another party involved in providing these services, or

Has the potential to become high profile or attract media/advocacy group
attention, or

Covers any other situation that ACC should reasonably expect to be
advised about.
Incidents may include:

The death of a client, or

Abuse or assaults by the client on a vendor or service provider staff, or
fellow patients (verbal, physical, or sexual abuse or assaults that result in
an internal incident form being generated), or

Media reports illustrating the client’s situation, or

A breach of house rules that may result in the client being evicted from
the facility, or

The client leaving the facility without permission, ie they are absent
without leave, or

The client being admitted to hospital for psychiatric or medical treatment

Any other events that would indicate that the client may be a safety and
security risk to themselves or others.
Exception report
When an exception occurs the vendor must notify ACC client service staff:

Verbally within 24 hours of the occurrence, or on the following working
day if the occurrence falls outside a working day, and

In writing within 2 working days by completing the ACC1382 form and
sending it to ACC client service staff, identifying the client and describing
the nature of the exception and subsequent steps taken by the vendor
(including any transfer of care).
Outcome Measurement
Outcome measurement is used to determine the client’s progress and their view
of their experience of health and wellbeing along the continuum of the
reassessment service. The vendor must ensure that at least two of the following
outcome measures are used:
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
Patient satisfaction survey

Short form health survey (SF36)

Spinal cord independence measure (SCIM)

Australian wellbeing index.
Service Monitoring and Clinical Review
Service monitoring
ACC will measure a provider’s performance against the service objectives by
analysing all relevant data reports and the results of aggregated outcome
measures.
Clinical review
Purpose
The clinical review allows ACC to evaluate the vendor’s delivery of services
against these Specialist Spinal Cord Injury Reassessment services specifications.
Frequency of clinical reviews
As part of the ongoing monitoring of this service ACC may conduct a clinical
review annually, or more often in exceptional circumstanced. The vendor will be
notified at least 1 month in advance.
Location
The clinical review will be conducted at the spinal unit.
Vendor responsibilities
The vendor will ensure that appropriate personnel and all relevant documentation
related to the service are made available to the ACC clinical reviewer on the
day(s) of the review.
ACC responsibilities
ACC will ensure that the:

Vendor is notified 28 working days before a clinical review, and

Clinical feedback review report is sent to the vendor within 28 working
days of the completion of the clinical review.
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APPENDICES
Appendix 1:
Remote Contact Screening Reassessment Questionnaire
General information
 When was your last assessment?
 What was it (Telephonic, Peripheral or Unit based Advanced)?
 Has there been any change to your caregiver since the last communication and
assessment?
(If Yes, who now provides care? (Family member(s), Private person, or
Agency?)
Wheelchair aids
 Is your wheelchair fully functional?
 Is your wheelchair causing any specific pressure points?
 Does anything need to be done about your wheelchair involving client service
staff (ie which you cannot organise yourself)?
Level of mobility and muscle function
 Has your level of mobility increased or decreased?
(If there is any change, is client service staff involvement required?)
Skin status
 Do you have any current or threatening skin breakdown?
(If so, do you require any client service staff involvement?)
Urinary status
 Do you currently have any UTI?
 How many UTI’s have you had since your last assessment?
 Do you have any continence or catheter problems?
Renal status
 Are you aware of having any renal stones at present?
Mega-colon
 Do you suffer, or suspect to be suffering, from bowel failure or faecal
incontinence?
(If so, will the client or assessor (ie the interviewer) arrange for any action in
this regard?)
Continued over…
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Chest care
 Do you currently have any chest infection?
 How many chest infections have you had since your last assessment?
 If any, have you received treatment for these from your general practitioner?
 Are you otherwise sufficiently concerned with the status of your lung function
to seek assessment?
(If so, please explain.)
Medications
 Are you on any medications at present?
(If so, please list the drugs and their dosages.)
Employment
 Are you presently employed in any income producing activity?
 Does this represent any change since your last assessment?
(If so, does this represent an increase or a decrease?)
Recreation
 Are you presently involved in any recreational activities?
 Does this represent any change since your last assessment?
(If so, does this represent an increase or a decrease?)
Psycho-social status
 Do you consider yourself to be depressed or mentally worn down?
 Is your client service staff member or general practitioner aware of this?
 Would you like your client service staff member or general practitioner to be
involved?
(If so, will the client or assessor (ie the interviewer) arrange for any action in
this regard?)
Substance addiction
 Do you consider yourself to be addicted or at risk of getting addicted to alcohol
or any drugs?
 Is your client service staff member or general practitioner aware of this?
 Would you like your client service staff member or general practitioner to be
involved?
(If so, will the client or assessor (ie the interviewer) arrange for any action in
this regard?)
Thank you for your cooperation.
This reassessment interview will allow staff to determine whether any additional
modalities are required.
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Appendix 2:
The Spinal Evaluation and Assessment Report (SEAR)
The SEAR report can be completed in the vendor’s format but must cover the
following information:
Client details
1
Client name, date of birth, and address
2
ACC claim number and NHI number
3
ACC purchase order number
Assessment details
4
Name and NZMC number of specialist who provided or is responsible for the
reassessment
5
Date, and type (ie outreach, outpatient, inpatient) of the reassessment
6
Facility/location where the reassessment was undertaken
7
Date, and type (ie outreach, outpatient, inpatient reassessment) of
previous reassessment
8
Detailed diagnosis of the client’s condition and his/her personal injury for
which cover has been accepted under the AC Act, level of spinal injury and
ASIA score
9
Details of the assessment modalities, diagnostic tests, and imaging
undertaken during (or in preparation for) the reassessment, including the
following:
 Wheelchair/aids review
 General physical exam
 Urinalysis
 X-ray (KUB)
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Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines
Assessment details - continued
10
Morbidity foci – the following aspects should be separately and specifically
addressed in the body of the SEAR:
 Wheelchair/Aids – condition, and adequacy, of wheelchair and other aids
to independent living
 Results of Transport for Independence assessment if this has been prior
approved by ACC
 Level of mobility/muscle function – loss of, or changes in, mobility and
muscle function, change in spasm management, presence of
contractures, etc
 Skin status – status of, problems with, skin integrity, presence of
decubitus ulcerations
 Renal status – presence of renal calculi and/or recurrence, degree of
renal failure or sepsis
 Urinary status – loss of, or changes in, bladder control, presence of
urinary tract infections
 Mega colon – loss of, or changes in, bowel function/control, presence of
faecal incontinence
 Chest care – presence of, and any treatment for, respiratory infections
 Medications – changes/increase in medications, usage of nephro or
ototoxic drugs
 Employment – changes in income producing activities
 Recreation – changes in recreational activities/exercise/hobbies
 Substance addiction – presence, or increase, of primary substance
addiction, eg cannabis, alcohol, etc
 Psycho-social status – level of social contact and support, deteriorating
psychological status, social disintegration, attempts at suicide, etc
Recommended further reassessment
11
Request to carry out reassessment modalities (if any), and the clinical
reasons why those modalities are indicated. The vendor must clearly
communicate (ie in ‘plain English’) the clinical justification for, and the likely
outcome of, the assessment modality or modalities being requested to help
ACC to make an informed prior approval decision. Advanced reassessment
modalities include:
 Complex urodynamics (eg cystometry)
 Advanced renal/urological assessment
 Lung function tests (other than spirometry)
 Advanced orthopaedic/plastic surgical assessment
 Neurological damage assessment
 Urological, sexuality and fertility assessment
 Blood tests – any test, standard and/or specialised
 Clinical psychological evaluation
 Psychiatric evaluation
 MRI/CT diagnostic imaging - up to two
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Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines
Recommended treatment
12
Any recommended non-surgical (conservative) treatment or rehabilitation
including GP care, aids and orthotic appliances, physiotherapy, non-surgical
intervention, etc
13
Clinical indications for any recommended surgical or non-surgical treatment
interventions, and details of other viable treatment options
14
Prognosis for any recommended surgical or non-surgical treatment
Certificate
15
A certificate signed by the specialist who carried out the client’s
reassessment, including any recommended treatment for the client.
The specialist must have discussed treatment options with the client and
the reasons for the recommendations.
ACC
SEAR received by client service staff:
Name:
Date:
Action to be taken on recommendations contained within report.
September 2009
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