Assessment in Medical Setting

General characteristics of the medical setting

Diagnostics in hospital setting

MODEL Setting Goal of the diagnostic process

Where does the problem rest?

How do we attempt to make changes?

Hospital Find cause, categorize problem

In client Address cause

Schools Characterize performance within setting

In client Change behavior

At home, in classroom (natural context)

Figure out which context promotes successful performance

Mismatch b/w client and context

Change context

Medical

Behavioral

Systems/social

General Characteristics of the Medical Model

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”

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

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!!

Medical Continuum of Care

• 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)

Why the changes?????

• Government funding of healthcare• Corporate need to contain healthcare costs

in a global economy• Focus on safe, effective and efficient care

Impact of Managed Care

Impact of Managed Care

• Third-party payers (e.g., Medicare, corporations)….

–pay fixed price for services

incentive for service provider to keep down costs

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

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)

Assessment Goals Vary by Assessment Setting

Think: What is role of this setting in the overall

continuum of care? How will that affect diagnostic goals?

Medical Continuum of Care

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

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

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

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.

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

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

MODEL Setting Goal of the diagnostic process

Where does the problem rest?

How do we attempt to make changes?

Hospital Find cause, categorize problem

In client Address cause

Schools Characterize performance within setting

In client Change behavior

At home, in classroom (natural context)

Figure out which context promotes successful performance

Mismatch b/w client and context

Change context

Medical

Behavioral

Systems/social

Practical Considerations

Once Assessment Goals Are Set, What Are Sources of Information for the Process of Information-Gathering?

1. Consultation request/referral

2. History

3. Examination

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.”

2: History

Doctor’s orders: “…Hx DM, HTN…”Doctor’s orders to other disciplinesMedical record: (p. 99 of readings)Physical and neurological examProgress notes : (p. 105 of readings)Lab reportsInterview of patient and family

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

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

3: Examination

Interview with familyInterview with patientTesting and examination

Interviewing patient and family

• Purposes (Equally important!)

– Information gathering– Getting interpersonal relationship off to good start

Interviewing patient and family

• Steps/principles of interview/assessment• What they are told before testing

….and for testing and examination…

If your goal is differential diagnosis, what are you looking for?

SymptomDeparture from normal in Fx, appearance, sensationSubjective, experienced by patient

SignAbnormality that is observable (by you, by M.D….)Objective

SyndromeConstellation of signs and symptoms

Scientific method Clinical method

Consciously consider each piece of info as it is received

Iterative Process !

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….

If your goal is to screen and monitor, how do you do this?

What kind of assessment procedure is typically used in screening?

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?