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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. September 2009 Page 1 of 18 Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines 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. September 2009 Page 2 of 18 Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines 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. September 2009 Page 3 of 18 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. September 2009 Page 4 of 18 Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines 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. September 2009 Page 5 of 18 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. September 2009 Page 6 of 18 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. September 2009 Page 7 of 18 Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines 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. September 2009 Page 8 of 18 Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines 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. September 2009 Page 9 of 18 Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines 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. September 2009 Page 10 of 18 Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines 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. September 2009 Page 11 of 18 Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines 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: September 2009 Page 12 of 18 Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines 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. September 2009 Page 13 of 18 Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines 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… September 2009 Page 14 of 18 Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines 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. September 2009 Page 15 of 18 Specialised Spinal Cord Injury Reassessment Services – Operational Guidelines 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) Continued over… September 2009 Page 16 of 18 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 Continued over… September 2009 Page 17 of 18 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 Page 18 of 18