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Effect of physical theraphy evaluation on care planning in frail elderly receiving case management

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Effect of physical theraphy evaluation on care planning in frail elderly receiving case management

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Content EFFECT OF PHYSICAL THERAPY EVALUATION ON CARE
PLANNING IN FRAIL ELDERLY RECEIVING CASE MANAGEMENT
by
Ronald Stephen Greenberg
A Thesis Presented to the
FACULTY OF THE LEONARD DAVIS SCHOOL OF GERONTOLOGY
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE IN GERONTOLOGY
December 1985
UMI Number: EP58916
All rights reserved
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a note will indicate the deletion.
Oissertatton PublisWrsg
UMI EP58916
Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author.
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unauthorized copying under Title 17, United States Code
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789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, Ml 48106 - 1346
uNjvERsny or s o u t h e d caiifornia (^e.mn
LEOUARO VAVIS SCHOOL Of GEHONTOLOGY
umvEnsny park
LOS ANGELES. CALIFORNIA 90007
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Tfucs tkeAZà, MVuXten bt/
Ronald Stephen Greenberg____________
unda/i the. dÂJitctoh. h Thefts Committez,
and appA.ovzd by a t t mzmbeA6, has been paz-
6zntzd to and azzzptzd by th z Vzan Thz LzonoAd
Vaots Schoot GzaontoZogy, tn p o A ttat iu Z itH m zyit
0^ th z AzqiuAzmznts {oA th z dzgAzz o i
y : / W
THESIS aOmiTTEE .
y ^ Q CkcUAsnan
Q9i ■ _________________
ACKNOWLEDGEMENT ’
Special thanks to Jennifer Chapman, Director, MSSP,
Jewish Family Service of Los Angeles, and the case worker|
staff, for their interest in, and support of, this project;
from its inception to its completion. I
11
DEDICATION
I dedicate this thesis to Marie Lishan who gave me
the inspiration and encouragement to enter the field of
gerontology and to continue its exciting pursuit of
knowledge and discovery.
Ill
TABLE OF CONTENTS
Page
ACKNOWLEDGEMENT................................... il
DEDICATION........................................ iii
LIST OF TABLES.................................... vi
Chapter j
STATEMENT OF THE PROBLEM.......................... 1
Introduction................................. 1
The Program Setting......................... 3 ,
Performance Evaluation...................... 4 i
Purpose of the Study........................ 4
Research Questions and Hypothesis........... 6 !
LITERATURE REVIEW................................. 9
Special Problems of the Elderly 9 .
Special Solutions for the Elderly 10 I
Measurement Issues ; Assessment by
Interview and Performance Evaluation 12 |
Care Planning Decision Making............... 14 j
Chronic Conditions Among the Elderly;
Medicare Guidelines for Rehabilitation
Services..................................... 15
DATA AND METHODOLOGY.............................. 19
Population................................... 19
Procedure.................................... 19 !
Measurement Instruments..................... 20 |
RESULTS............................................ 27 j
I
!
Client Characteristics...................... 27 |
Comparing Functional Mobility (ADL) |
by Oral Interview and Performance
Evaluation................................... 28
Care Plan Changes After Physical
Therapy Evaluation........................... 30
Why Clients Not Originally Referred
for Rehabilitation Services................. 30
Changes in Perceptions of
Case Managers................................ 31
I V 1
. ,_..j
Chapter
Key Findings of Performance Evaluation
DISCUSSION..................................
Client Selection and Characteristics..
Oral Interview Versus Performance
Evaluation.............................
Perceptions of Functional Mobility....
SUMMARY AND RECOMMENDATIONS................
Summary and Findings..................
Recommendations.......................
REFERENCES..................................
APPENDICES..................................
Page
31
34
34
37
40
42
42
44
46
53
V
LIST OF TABLES
Table Page
1 Client Information..................... 48
2 Functional Scores of Homebound
Elderly Clients by Oral Interview
(MSSP) and by Performance Evaluation... 49
3 Care Plan Changes by Case Management
After Physical Therapy Evaluation..... 50
4 Changes in Case Workers' Perceptions
of Clients for Rehabilitation Services
Before and After Physical Therapy
Evaluation.............................. 51
5 Key Findings in Performance Evaluation
Which Changed Case Managers' Perception
of Clients' Functional Mobility....... 52
VI
L_.
STATEMENT OF THE PROBLEM
Introduction
' Although older people comprise just 11 percent of the
' total population, they account for 29 percent of the
! national expenditure for personal health care (Pegels,
I
1980). Yet, in spite of the disproportionate use of
health services by the elderly, there are reports of gross
' underutilization of services by the elderly for a variety
of reasons (Besdine et al., 1982). The wide array of
, services, with their disconnected nature, contributes to
the difficulty with access to health services for the
elderly. To help manage both scarce resources for the
I ^
' elderly, and to match client needs to available health
. services, a system to integrate and coordinate health
! services for the frail elderly, called case management,
has emerged. In California, a case management program
I
called the Multipurpose Senior Services Program (MSSP) has |
been funded by the state since 1982. Many services which
are not available through conventional Medicare and |
I I
^ Medicaide guidelines, can be purchased by waivers through,
i MSSP. In order to qualify for case management through !
; MSSP, clients must be, among other things, at risk of !
institutionalization. Clients must be in very frail
condition. Case managers often must decide when to call
, for rehabilitation services and/or to assign home support !
: services in order to maintain their clients at home.
!
' Assigning various services to clients, and staying within
I the authorized budget, is a function of case management.
Rehabilitation services are relatively expensive and are
■ used sparingly. The chronically disabled elderly client ;
is often denied rehabilitation services, through home
; health agencies, because of chronicity of problems and
I
estimates of poor rehabilitation potential by health
t
I professionals. The latter group, frequently underestimate
rehabilitation potential of the frail, chronically
disabled older client. Multiple physical problems,
depression, learned helplessness, and "ageism" (Butler, j
1969) all tend to contribute to the "acceptance" of I
1
chronic disability by both client and health professional t
thus dampening efforts to secure restorative care..
Against this background, case managers must develop care
plans based on an interview assessment of their clients.
Their perceptions of their clients' functional mobility
■ and their need for support services, including !
I I
rehabilitation potential, will be key factors in care |
I
planning. While assignment of rehabilitation services by |
case managers may be clearly justified in most instances, I
it is not clear in all clients. There is a group of
Program clients among the general MSSP caseload for whom
case managers are seeking a further opinion. Thesei
: i
clients may be depressed, show marked dependency, and/or
, have changes in their health status due to injury,
! disease, and medical management. This group of clients
; represents the most vulnerable group in so far as
rehabilitation is concerned. They are frequently excluded
from rehabilitation services by licensed home health
I agencies due to non-reimbursement from governmental
' insurance programs. They do not appear to have
I
j rehabilitation potential and often a recent and
appropriate diagnosis is lacking. To compound the
problem, there is a tendency for physicians to under-
. utilize home health services for their patients (Steinberg
and Trejo, 1984). These clients may simply "fall through ■
; the cracks" so to speak, and aren't considered for
rehabilitation services.
I
The Program Setting
The Multipurpose Senior Services Program (MSSP) in i
California allows great flexibility in use of resources |
I
and services for qualified seniors. Clients must be very j
I
I frail, chronically disabled, homebound and at risk of*
I institutionalization. The case management team is|
I
* composed of a social worker and a registered nurse. They
must assess the client, establish a care plan and
^ 1
, coordinate all services for the client. Decisions by case !
managers are made based on their interview assessment of
!
I clients. Their perceptions of clients' functional
. mobility and potential for restoration are key elements in
(
I their care planning.
!
Performance Evaluation
An interview assessment may not reflect true
performance ability of clients. Factors such as client
, motivation, goal perception, self image of wellness or
disability, fulfilling the sick role, and eligibility I
requirements can affect self reporting of health status
and function. A performance evaluation, on the other
hand, tests the clients actual ability to do basic
i activities of daily living (ADL) such as bed and chair
mobility, transfers to toilet, tub and shower, and
I ambulation. Demonstrating the effect on care planning of
I
a one-time physical therapy (performance) evaluation of a j
I
selected group of MSSP clients will help establish '
criteria for referring clients to rehabilitation services. |
!
!
I
Purpose of the Study '
This study examines the impact of a physical therapy |
' (performance) evaluation on care planning of frail,
, chronically disabled, elderly clients. Physical therapy
I
is often denied to the chronically disabled client as it
is assumed that they have little or no rehabilitation
I potential and that functional gains cannot be made in a
"reasonable" period of time. In this study, a group of
very frail elderly clients, were selected by their case
managers on the basis of clients' questionable ability to
utilize rehabilitation services. They represented a sub
group from the MSSP caseload because case managers needed
a further opinion on their rehabilitation potential.
A second purpose of this study was to determine how j
i
case managers perceived their clients' functional mobility ;
before and after they learned the results of the j
performance evaluation of their clients. Prior to the I
performance evaluation, case managers' perceptions were j
I
based on their interview assessment of the clients.*
Clients answered a series of probing questions about their'
ability to perform basic activities of daily living as,
well as the nature and extent of help they were using to j
I
perform an activity. Care planning was based on answers
provided by clients and on overall perceptions by case i
managers about clients' physical and psycho-social status. j
After the results of the physical therapy performance
I
evaluation were known by case managers, their perceptions'
of their clients' functional mobility was re-examined.
The purpose was to discover changes in their perceptions
and the effect these changes had on their care plans.
Finally, specific criteria were developed in order to
!
, identify clients who could benefit from a physical therapy
j performance evaluation. Criteria were based on clients'
! characteristics which were most frequently associated with
' discrepancies in findings between the interview assessment
, and the performance evaluation, and on perceptions of case
■ managers which were most changed by performance
I
I evaluation.
: Research Questions and Hypotheses
The following research questions are proposed and
will be investigated in this study:
1. Does a physical therapy evaluation of functional
mobility of chronic, homebound and frail elderly
show differences in ADL from findings by oral
I interview with a case management team?
, 2. What changes in care planning was immediately ■
effected by case management teams following a |
I
one-time physical therapy evaluation of !
chronically disabled homebound elderly clients? |
3. What are the perceptions of ADL abilities by
case managers that differed from physical I
therapy findings and what were the key findings j
in the physical therapy evaluation which refuted
I
the oral assessment's perceptions of client
mobility?
4. How can each evaluation (oral and performance)
be enhanced so that the oral assessment can get
a clearer picture of client's functional ability
and the performance evaluation derive more
information on client's psycho-soc ial and
environmental factors which affect daily
performance?
Hypotheses for this study are as follows : j
1. A physical therapy performance evaluation will j
t
reveal higher functional mobility than isj
perceived through oral interview of clients by |
case management. j
j
2. A one-time physical therapy evaluation will'
provide information about clients' mobility that,
will change case managers' perceptions of;
clients' functional mobility. j
3. Case managers will refer clients for;
rehabilitation services, and/or reassign duties|
of home health aides to include higher levels of,
I
client functioning, after a one-time physical |
therapy evaluation. |
4. Criteria will be developed that will identify ;
clients that should be referred for physical
therapy evaluation by a case management system.
8
literature REVIEW
Special Problems of the Elderly
Appreciation of the compound problems of the aged is ;
essential to any therapeutic program. The prevelance of I
disease and disability rises steeply with age. Although i
I
the population over 65 years of age comprises only 11 ;
percent of the American people, they spend 29 percent of ;
' the total dollars on health care and use 25 percent of all :
prescription drugs. Besdine et al. (1982) has identified |
the elderly at high risk of institutionalization by age |
I (over 75), by living situation (alone), and by functional !
I
I state (recently bereaved or hospitalized, incontinent, j
immobile, or demented). Under-reporting of illness by the ,
1
elderly is partly responsible for advanced disease states :
and disability. Ageism is the most common explanation for j
, the elderly tolerating and not reporting symptoms.
I Another case is depression among the elderly. A third
I explanation is intellectual loss. Our present health care ,
I system is passive, especially for the elderly, and lacks 1
! prevention or early detection efforts. Multiple
pathologies also predispose elderly individuals to decline j
! due to late detection of illness. The number of diseases '
per individual is strongly age-related and can rise to
more than a dozen in the very old (Besdine et al., 1982).
J Access to long-term care services presents another
I special problem for the elderly. The vast array of
services has been described by Brody (1979) as a continuum
I of care which spans from least restrictive (in-home and
community settings) to most restrictive (institutional
, settings). The vast array is rarely if ever available in
^ a given place for any given time. The task of matching
I
clients with available services generally requires!
i
* j
assistance from a variety of professions. This task may
be time consuming as well as frustrating for busy
! physicians who may not know what services are available or
how to obtain them.
: I
Additional problems associated with long-term care i
services to the elderly have been enumerated by Callahan !
and Wallack (1981) as follows : (1) Fragmentation of
I services and programs; (2) Service gaps; (3) Duplication;
(4) Programs working at cross-purpose ; (5) A lack of ,
i
comprehensiveness in service arrangement and delivery;
and (6) Multiple needs of the elderly client that can be j
I
addressed only by a coordinated service approach. j
' i
1 I
I Special Solutions for the Elderly |
Case management is seen as a way to address the
foregoing problems perceived in the way long-term care
10 i
services are organized and delivered. According to ;
Callahan and Wallack (1981), case management attempts to
treat these problems in the following ways: (1)
Integrating and individualizing long-term care services;
(2) Helping clients gain access to a continuum of
I services; (3) Assuring that services given are appropriate
for the problem of a particular client; (4) Facilitating
and development of a broader range noninstitutional
i
services. Case managers thus work to lessen
I
maldistribution of resources within the system and to
increase total dollar flow to the sector in the form of
new services ; (5) Following clients to guarantee continued|
1 appropriateness of service; and (6) Assuring that services j
I
are provided in a coordinated way to meet multiple and
diverse client needs. They describe case management as a ;
policy to maximize resources through the integration and
individualization of benefits available from existing,
programs. I
Rehabilitation of the chronically disabled elderly
requires a special knowledge and approach which differs ;
from the rehabilitation of the young in three major ways ,
(Libow and Sherman, 1981), as follows : (1) The goals of
I ' •
older individuals, after disability, will generally be to '
return home to independent living in the community. His
younger counterpart will likely have expectations of
' 11
returning to his vocation or to train for a new job.
Returning to independent living in the community means
independence in mobility and the ability to perform daily
basic self-^care needs (activities of daily living [ADL]);
(2) Obstacles encountered in rehabilitation of the elderly ;
will differ from younger persons in the following ways: ,
a) Lack of motivation most often due to depression ; b)
: Lack of vigor or energy usually due to low reserves ; c)
Poor mentation secondary to organic brain syndrome ; d)
I
I Tendencies for disabilities to recur; e) Tendency to lose *
mobility from a variety of physical, emotional and
behavioral causes; and f) Difficulty in establishing a '
I
therapeutic relationship secondary to differing ;
priorities, attitudes and expectations of the client and ;
the health professional; and (3) Rehabilitation processes ;
would be expected to be slower than in younger people !
because of declining physiological functions in the !
elderly.
i Measurement Issues: Assessment by Interview and |
I
: Performance Evaluation
Two methods of assessing functional mobility were
; used and compared in this study. Kane and Kane (1981) in
' discussing a client assessment instrument states that
client performance is influenced by motivation and
, opportunity. They state that a case manager or caregiver'
* needs to determine actual capabilities, apart from
environmental constraints, in order to make a plan that
permits achievement of functional potential. Also when an'
i
! instrument is used for research and evaluation assessment i
* they caution that the test should minimize bias due to
reliance on clients as informants if clients' benefit
structure of eligibility status is at stake (or is
perceived to be jeopardized) as a result of responses.
j They add that in this case, validity may be threatened.
I In a review of several Activities of Daily Living (ADL)
instruments specifically designed for the elderly, they
promoted one instrument which they believed offered an
added dimension to ADL and lADL (Instrumental) testing.
This instrument is called the PADL (Performance Activities >
of Daily Living). The PADL was designed to clarify the
ability to actually perform functions and the opportunity,
to perform them in any given environmental setting.
Subjects actually demonstrate their ability to do 16 tasks,
of daily living. Use of the PADL instrument was reported |
1
by Kuriansky et al. (1976). They reported that results,
with the PADL were more consistent with informant reports
(family and/or caregivers) than were self-reports of,
functional abilities. Furthermore, the PADL had a higher ;
predictive validity in terms of disposition three months i
i _
I later than did either informant or self-reports.
I
Care Planning Decision Making
I Kane and Kane (1981) summarized the problem of care
I
I planning in the following way: "The question is how to
I make efficient use of the sometimes voluminous information
I
’ to assist in clinical decision making." They state that
' assessment in long-term care is made in two general ways :
(1) By professional judgement based on knowledge and
I
I experience, and (2) By predetermined decision rules. They
I
' observe that the bulk of work in long-term care (LTC)
j assessment involves a systematic and detailed data base
■ which will, it is assumed, enhance effectiveness of
j professional judgement. The actual prescription decisions
! in such a method are left to the interpretation of the
I
I clinician. Although less highly trained individuals may
1 make the observations and complete assessment instruments, i
! the professional (or the team) must review the material
: and make the plan, they conclude. Sager (1979) presented
standardized case "scenarios" to professionals, who, in
turn, were asked to prescribed appropriate home-care
service packages. He found a great discrepancy across
\ providers. Predetermined decision rules on care planning
' can be achieved only after clinical consistency is
I achieved (Kane and Kane, 1981).
14
Chronic Conditions Among the Elderly; Medicare-Guidelines I
' for Rehabilitation Services '
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I
I Libow and Sherman (1981) attempted to show basic|
, "normal" aging changes and their relation to illnesses,
i symptoms, signs, and problems typical of the elderly.
They listed 50 "normal" aging changes occurring in the
human body and their possible extrapolation to typical
health problems of the elderly. They stated that although
. Medicare, Part A and B together, allows up to 200 home
visits for the homebound elderly even this quantity may be
insufficient for the very ill homebound. Total visits
include all those made by the nurse, physical therapist,
• speech therapist, occupational therapist, home health
■ aide, and physician. Pollack (1979) stated that a central|
issue is whether personal and maintenance care services I
should be provided on a long-term care basis to persons in
the community who need such services, even if they do not |
need medical or "skilled" services on a frequent, regular I
basis. He notes that personal and maintenance services|
will be provided only in conjunction with skilled home j
, care services to persons who need both. Medicare !
guidelines (205.5) for physical therapy services require j
' that the patient will improve significantly in a j
reasonable, and generally predictable time period. The
I
15
regulations go on to say that these expectations may not
always prove to be valid, and the realization that
restoration will not occur can and should also be reached
in a reasonable and generally predictable period of time.
The regulations also say that physical therapy services
may be provided to establish a safe and effective
maintenance program required in connection with a specific
disease state. The maintenance program is established
within one to two visits by the rehabilitation specialist
and is then carried out by family members or a home health ;
I
aide. i
Definitions of health, using the current medical
model of treatable acute disease conditions, may not be
I appropriate for the elderly. A functional definition of
I health has been advocated by the World Health Organization
I
I Advisory Group (In Binstook and Shanas, 1976). They
; redefined health as "...health in the elderly is best
I
I measured in terms of function;...degree of fitness rather
I
j than extent of pathology may be used as a measure of the
j amount of services the aged will require from the
I community." Chronic non-orthopedic medical conditions can j
I sufficiently diminish function so as to require physical
* _ I
therapy rehabilitation services. In a report by Parris
. (1974) on home health services based at a New York i
i
; Hospital, the most common diagnosis among the 2 52 patients !
16
: treated by physical therapists was cardio-vascular |
disease, followed closely by diabetes mellitus. |
' Kane and Kane (1981) recommended that all physicians, i
! nurses, and social workers who provide direct care to the
' elderly incorporate ADL and lADL indicators into their
' routine assessments. They concluded that LTC measurements
of function would profit by the establishment of some
' common, easily learned and used measures that might
!
provide a common vocabulary for the generalist and the
■ geriatric specialist. They urged that care planning for
the elderly must revolve around their functional abilities
; regardless of whether the client is in an acute hospital
or a community based setting.
Callahan and Wallack (1981) in discussing barriers ,
within the LTC system, explained how existing service '
resources strongly skew clients toward an institutional
i setting. Both capacity for, and availability of, services
, for the disabled elderly are more abundant for ;
institutional (nursing home) placements than for any other
care setting. They further defined the problem as ,
follows; "A medical system that serves the acute care ,
health problems has flourished, independently of the
locally-based social service system. Neither system
claims responsibility for the LTC patient whose needs span I
I
both systems. Buck passing persists in this environment, j
: 17 !
; which has not developed appropriate linkages." Current
case management systems, however, are geared toward
preventing institutionalization. Nevertheless, if a
- client must go to a long-term care facility, he or she is
I followed by the case management team in order to
: facilitate return to a community based setting.
18
data and methodology
Population
Six frail, homebound, elderly clients with chronic
I
' disabilities (Appendix A) were volunteers for the study.
Each client was currently receiving case management
through the Multipurpose Senior Services Program (MSSP)|
(Appendix K).
Selection of clients for the study was made by MSSP
case managers and was based on the following criteria:
I 1. Case managers wanted a further opinion on the
I rehabilitation potential of their clients.
2. Clients had not hitherto been referred for
rehabilitation services and were considered
questionable candidates for such services by
their case managers.
3. Case managers considered a physical therapy
evaluation potentially useful in helping them to
determine actual physical abilities of their
clients.
Procedure
Sequence of data collection in this study was as
follows :
19
1. Client was referred to study by MSSP case
manager (Social Worker) using referral form
(Appendix B).
2. Human subjects consent form was signed (Appendix
C) .
3. Performance evaluation was conducted which
included a brief medical and psycho-social
history (Appendix D).
4. A physical therapy care plan was formulated
(Appendix G) based on the performance
evaluation.
5. Functional mobility data was extracted from the
interview assessment instrument (MSSP) in order
to compare it to the performance evaluation|
(Appendix H). j
6. Interviewing of case manager by the principal'
investigator in this study was conducted|
(Appendix I). j
Measurement Instruments
i !
Performance evaluation : The physical therapy'
I I
I performance evaluation used in this study was constructed■
: from the "Functional Mobility" section of the MSSP
interview assessment and from the "Physical Therapy
Evaluation" instrument employed by the Visiting Nurse
20
Association of Los Angeles, Inc. (VNA) (Appendix J).
; Basic activities of daily living (ADL) were measured i
' in this study. Basic ADL is defined as gross functional ;
ability to use bed, chairs, toilet and tub, and ability to '
' ambulate, including stairs. Since all of these items were
part of the MSSP instrument interview, they were included
in the performance evaluation. Grading of basic ADL
I utilized a system in effect at Rancho Los Amigos Hospital,
I
! Stroke Rehabilitation Unit, Department of Health Services,
i Los Angeles County. Grading was defined as follows:
Independent (I) - subject can perform function safely,
without personal assistance or supervision, with or
without assistive devices; Supervised (S) - client
requires stand-by presence of another person for safety
j and/or for verbal cues; Assisted (A) - subject requires
j physical support from another person in order to perform
! the function, with or without assistive devices; Unable
I I
(U) - subject is judged as incapable of performing]
function even with physical assistance of another person. >
I
The performance evaluation used in this study,
i
contained all elements found in the "Physical Therapy|
Evaluation" used by the VNA. Sections on "Passive Range
! I
, of Notion and Muscle Strength" and "Physical Therapy
■ I
Performance Evaluation (ADL)" in this study were expanded|
I
' versions of the VNA form.
21 !
Interview Assessment Instrument (MSSP); This health
assessment instrument was a product of the California
; Multipurpose Senior Services Project (MSSP) Evaluation
I Unit of the State of California Health and Welfare Agency.
I It was developed under the supervision of James Lubtoen of
the Agency and many health professionals of MSSP sites who
reviewed numerous drafts of the form and offered
I
t
! suggestions for improvement. It is an interview
I assessment of clients' social, functional, physical, and
; psychological status. A nurse practitioner and social
; worker team had primary responsibility for obtaining
I assessment information. The clients' existing levels of
I service utilization and informal support was also
1
I determined by the assessment. A series of probing
I
j questions is asked of the client in order to determine his
I functional status. Questions are pre-determined and are
j directed along a flow chart method, determined by previous
I
I answers by the clients.
' Procedure; The sequence of data collection in this
, study is presented as follows ;
1. Client is referred to study by MSSP case manager
I (Appendix B).
! 2. Human subjects consent form is signed (Appendix
I
i C) .
: 22
3. Performance evaluation (physical therapy) is
conducted which includes a brief medical history
(Appendix D), joint range of motion examination
and muscle strength and pain evaluation
(Appendix E), and evaluation of functional
mobility or ADL (Appendix F).
' 4. Formulation of a physical therapy care plan
(Appendix G).
i
1 5. Data extraction from MSSP's oral instrument
j
j section on "Functional Mobility" (Appendix H)
i
! and data recording form (Appendix L).
i 6. Interview of case manager including presentation
■ of performance evaluation and physical therapy
care plan (Appendix I).
Performance Evaluation: The physical therapy
I evaluation in this study contained all elements found in
I the initial physical therapy evaluation used by The
j
I Visiting Nurses Association of Los Angeles (VNA) (see
Appendix J). Sections on "Passive Range of Motion and
I Muscle Strength" and Physical Therapy Performance
I Evaluation" in this study are expanded and more detailed
I than the VNA form.
! The Physical Therapy Performance Evaluation component
; was composed of basic ADL items of bed mobility, transfer
' ability and walking. Grading is defined as follows:
23 I
' Independent (I) - subject can perform the function safely,
I
I without personal assistance or supervision, with or
I without assistive devices; Supervised (S) - client
1
I requires standby presence of another person for safety
i and/or for verbal cues ; Assisted (A) - subject requires
j physical support from another person in order to perform
I the function; Unable (U) - subject is judged as incapable
I of performing function even with physical assistance of
I
' another person.
I
I The Physical Therapy Care Plan was formulated based
! on the foregoing evaluation. A problem list was generated
I
I from the data and both short-term (2 to 3 weeks) and long-
I term (4 to 6 weeks) were projected based on clinical j
I
I
experience and judgement. A treatment plan was i
recommended by the physical therapist based on the problem I
list and goals. {
j Data Interpretation of Functional Mobility from Oral :
j . :
1 Assessment: Data extracted from the MSSP instrument was ,
! taken from subsections as follows : "Mobility Functioning]
!
I Information" ("Stair Climbing," "Walking" and "Getting
I I
I Out of Bed, Chairs, etc.") ; and "Personal Care Functioning i
Information" ("Bathing," and "Toileting"). From this
information a performance evaluation was constructed to
match the items assessed by the MSSP instrument. The
‘ physical therapy evaluation then included mobility items
24
as follows: (1) Transfer to bed and chair; (2) Transfer
to toilet; (3) Transfer to tub or shower; (4) Ability to
j walk indoors; (5) Walking outdoors ; (6) Ability to walk
I more than one block ; and (7) Stair climbing.
! MSSP data were re-classified into categories used by
I the physical therapy evaluation. An interpolation was
made from client responses to a series of questions
relating to their functional mobility. For example, the
oral instrument asked the client if he or she climbed
I stairs. If the answer was "yes," then the examiner asked
! if anyone helped client climb stairs. If the answer was
"no," then a reclassification was made for "Independent."
^ If client answered "yes" to help, then the interpolation
' was for "Assisted." Where doubt was cast on a
I
i reclassification it was elucidated by the oral interview
I I
I of case manager by the investigator in this study. I
j j
1 Oral Interview of MSSP Case Manager : This was the j
' (
' final phase of data collection. The interview was i
' I
conducted by the physical therapist. Answers were
!
j recorded in written form by the interviewer (Appendix I),
j Purpose of the interview was two-fold, as follows : (1) To j
! ascertain case workers' perception of clients' functional |
, mobility status before and after results of performance j
I
; evaluation were made known to them ; and (2) To determine
key factors in the performance evaluation which changed
25
case managers' perceptions of their clients' functional
mobility.
Data Analysis; Data collected for this study are
qualitative. Only one set of datum, that of functional
mobility performance levels, was coded into a number
sytem. Designation of functional performance by a number
system as used in this study was not intended to be
quantitative. Usage of the number system of designating
, degree of dependence and independence is discussed in this
■ paper ("Discussion" section). All data in this study is
! arranged in tables showing each client individually and
I generally is discussed on a case by case basis.
26
RESULTS
I
Client Characteristics
; Six chronically disabled, homebound, elderly clients
I were subjects for this study (Table 1). All were female,
; currently receiving case management from the Multipurpose
Senior Services Program, and at risk of
institutionalization of long-term care facilities. Age
I ranged from 78 years old (client #4) to 92 years (clients
' #2 and #3). The remaining clients (#6, #1 and #5) were
82, 88 and 90 years of age, respectively. Treatment
; diagnosis (primary diagnoses most responsible for clients
being homebound) can be categorized as follows:
Orthopedic injuries (clients #1, #2 and #6); Residuals of
i stroke (CVA) (clients #3 and #4); and Medical
I
I complications (client #5). Onset dates may be grouped as
I follows: Less than one year (clients #1, #5, and #6); and
I more than 1 year (clients #2, #3, and #4). Clients had
!
' from one to five other medical diagnoses for which
' prescription medication was necessary: Heart disease was
present in all 6 clients while depression, requiring
medication, was found in clients #2 and #4. All clients
: required assistive devices for ambulation. Living
arrangements may be grouped as follows: Living alone
27
] (client #1); Living with immediate family (clients #4, #5,
! and #6); Living in board and care homes (clients #2 and j
I #3) .
' Comparing Functional Mobility (ADL) by Oral Interview and
* Performance Evaluation
There were discrepancies in ADL scores, for each of
the6 clients, between MSSP oral interview of clients and
the physical therapy performance evaluation (Table 2), as
I follows : Client #1 showed differences in tub transfer,
outdoor and stair ambulation; Client #2 had differences in
; all mobility tasks except tub transfer and walking over 1
I block; Client #3 showed differences in tub transfer and
I outdoor ambulation; Client #4 for outdoor ambulation only;
[ Client #5 for bed and chair transfer and indoor
! ambulation; and Client #6 for ambulation outdoors, over 1 i
I !
I block, and stairs. Walking outdoors showed the highest■
I frequency of discrepancy (all clients except #5 who was
non-ambulatory), followed by stair climbing which differed
, in scoring in clients #1, #2 and #6. All ADL scores which
' differed, with the exception of only 3 scores, were graded
I higher (more functional) by the physical therapy
I evaluation. There was concordance in roughly two-thirds
! of ADL items tested.
28
When the coded ADL scores are added up for each
j
: client, a total ADL score results (Table 2). A total of
I 21 points is possible if the client is "Independent" in
j all mobility tasks. Generally there was close agreement
I between the two types of evaluations except for client #2
j who showed a marked discrepancy (MSSP 3; P.T. 13). the
discrepancy was due to the case manager’s perception of
I this client as a non-ambulator. Patient was ambulatory at
j the time of the performance evaluation.
I Degree of disability appeared to be of far greater
; importance than age for total ADL scores, in this study.
The youngest client (#4), at 78 years of age, was
physically more disabled than the two oldest clients, both
92 years of age. The youngest client had right-sided
J hemiplegia from multiple CVA’s. One of the older clients
! (#3) also had residuals of a hip fracture but she was not
j neurologically impaired as was the youngest client with
I CVA.
I
Whether the client lived in board and care or at home
also did not have a bearing on total ADL score. However,
I
I the two clients (#4 and #5) with the lowest total scores
j (2 points each) lived at home with close relative (husband
I and daughter, respectively), acting as a primary
I
I caretaker. Client #4, who husband was medically disabled
(partially), also had a live-in attendant. In contrast.
29
the only client who lived alone, in her own apartment, had
' the highest total ADL score (client #1 - 18 points).
i
1
j Care Plan Changes After Physical Therapy Evaluation
j Immediate changes in care plans for all 6 clients
i were made by case managers after they learned results of
i
the physical therapy performance evaluations (Table 3).
Clients #1, #3, #4, #5, and #6 were referred for
rehabilitation services. Client #2 was found to be able
to ambulate downstairs and out of doors with assistance.
Outdoor ambulation with assistance by her personal care
aide was immediately added to her program. Sitting up in
a chair was immediately added to client #5's home program.
She was considered as bedfast by her primary caretaker
I (daughter).
Why Clients Not Originally Referred for Rehabilitation
j Services
I Reasons for case managers not originally referring
I clients for rehabilitation services may be grouped as
I follows (Table 4): It was assumed taht clients #1 and #6
I
I would improve to their prior level of function
(Independent) as soon as their casts were removed; Client
' #5, it was believed, had too many medical crises and too
frequent hospitalizations and that she would return to her
30
; prior level of function when these medical problems
cleared; Clients #3 and #4 were believed to be too
depressed and poorly motivated to benefit from
I rehabilitation services; Client #2 was considered to be
I too physically frail and depressed, as well as being
I
I considered a non-ambulator, by her case manager.
Changes in Perceptions of Case Managers
After physical therapy performance evaluations and
f
I
j presentation of results and a care plan, perceptions of
I
I case managers toward their clients changed (Table 4).
I
I Clients #2 and #3 were now considered to be less frail
] than originally perceived. Case manager for client #1 now
perceived restrictions which were not previously picked up
I
by oral assessment. Case manager for client #5 learned}
I
that client's bed dependency was due, in part, to her j
: I
; daughter's anxiety about her mother's condition (fainting|
: episodes). Case managers for clients #4 and #6 perceivedi
I only a possibility of their clients upgrading their
I
I functional mobility depending upon a success fulj
I rehabilitation outcome. {
I I
I
! I
Key Findings of Performance Evaluation |
Key findings of the physical therapy performance
evaluation which differed significantly from perceptions
31
! of case managers about functional mobility of their
clients are summarized in Table 5. Clients #2, #5 and #6
were found to be able to perform at a higher level than
their oral interview indicated. Client #2 was able to get
I
i out of bed and walk with a walker, including stairs by
I
I holding hand rail with both hands. She had been judged by
j oral interview as unable to ambulate stairs, and needed
I assistance to get up, out of bed and ambulate. Client #5,
i it was discovered, was able to walk in a walker, with
standby assistance of 2 persons, up to 10 feet. Her case
; worker did not consider walking as possible because of her
j dependency. Client #6 showed ability to independently
I ambulate stairs (5 steps) that lead out of her apartment
I building and to be able to walk unassisted ( with I
! supervision) outside. It was thought, by her case
, manager, that she required assistance to use stairs and j
I walk outside. j
I I
I j
] Key findings for clients #1 and #4 tended to lower .
; expectations of clients' functional mobility by case I
managers. Case manager for client #1 expected that her ;
client's knee injury would improve on its own. She was i
i
found to have, by performance evaluation, complications of |
her knee injury and cardiovascular limitations which ;
prevented her from reaching expectations of her case
j
manager. She had a fixed knee joint limitation (10 degree !
32
i flexion contracture) and weakness of both lower
extremities. Also, her cardiovascular endurance limited
' her, by shortness of breath, to one-fourth a block. Case
manager for client #4 believed her client had the ability
I to function at a higher level were it not for poor
j psychodynamics. However, she did not show performance
ability beyond case worker's perception of her potential.
Case worker for client #3 perceived her client as very
dependent and using it to enlist more help especially from
her family. Performance findings show functional
capability beyond the dependency state. She was able to
transfer in and out of tub and to walk with walker, both
without physical assistance (supervision only).
33
DISCUSSION
Client Selection and Characteristics
Selection of these 6 .clients by 5 different case
managers, for this study, was made in order to help case
I managers decide if rehabilitation services were indicated,
j Case managers were seeking a further opinion on the
I
: questionable rehabilitative potential of these clients.
: Such underlying factors as frailty, depression coupled
with poor motivation, medical complications, and psycho
social dynamics clouded the restorative picture. Yet the
j
I very questionable nature of their functional abilities, in
i the minds of the case managers, proved to be significant
I for selecting a group of clients who did benefit from a
I one-time physical therapy evaluation. Immediate changes
I in care plans resulted in two clients (#2 and #5) and all
I but one client was referred for rehabilitation services,
i Perceptions of case workers changed significantly
! also. When actual performance ability became known to the
case managers, they were able to deal with this particular
I group of clients more effectively. For example, if it
i
! became known that the client could perform a particular
! task but was too depressed to want to try, case managers
34
could focus in on the depression and not on the physical
I
1 inability.
In that these clients do represent a particular
group, the questions arises whether they are significantly
I different from the "typical" program client of MSSP's
I current population. Based on assessment data of the
I
I current MSSP caseload the "typical client profile" emerges
I
(California Health and Welfare Agency, 1984). This client
is described as a low-income, 82 year old Caucasian widow
who lives alone in an apartment. She has 5 chronic
^ conditions. She reports that she cannot perform 2 of the 6
basic activities of daily living (ADL) nor perform 6 of
I the 8 lADL items. In this study, 4 of the 6 clients were
' 88 years of age or older, significantly older than the
i
"typical" client. All were Caucasian females, typical of !
: I
i the MSSP population (75% female). All clients in this]
I study reported (by oral interview) more than two bsic ADL
I tasks for which help was needed (between 4 and 7 tasks)
i which indicates a much more disabled sampling than the
I
! general MSSP client. Even by physical therapy performance
!
evaluation, 5 of the 6 clients needed help with between 3
and 7 basic ADL items. Only one client (#1) needed help
with 2 or less basic ADL items. This same client was the
only one in this study to live alone while the majority of
MSSP clients live alone. Only 7 percent of MSSP clients
35
live in board and care while, in this study, 2 of the 6
clients (33%) lived in such facilities.
The most common chronic diagnosis found among
clients, in this study, was heart disease. In a review of
252 geriatric patients receiving physical therapy from a
hospital-based home health service, the most common
diagnosis of the patients was cardiovascular disease,
followed closely by diabetes mellitus (Parris, 1974).
Although heart disease among clients in this study was not
necessarily the treatment diagnosis, its effect on
I functional mobility was very great. For example, three of
the six clients (#1, #2, and #3) were limited in walking
' distance by shortness of breath, a probable side effect of
I heart disease. Although heart disease in itself is not
I considered by Medicare guidelines as a diagnosis which
I requires skilled rehabilitation services, its underlying I
; effect on mobility and endurance should be considered in a|
restorative program. I
I !
i Restrictions placed on home health services for the |
elderly, denying home care because of chronicity of
I
! problems, do not take into consideration slower recovery
I
times, and often more complicated recovery courses. With
so many possible "normal" age changes (Libow and Sherman,
i 1981) occurring simultaneously with an injury e.g., hip
fracture or fall, they impede recovery and certainly make
I
I _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 36 _
j even a minor disease or injury into a greater disability
t
' and a longer, more complicated, rehabilitation.
I
I
I Oral Interview Versus Performance Evaluation
! It would be convenient to suggest that the MSSP oral
j interview is not as sensitive as a performance evaluation
I except that the differences in this study were
overwhelmingly unidirectional. Scores by performance
evaluation were consistently higher (for greater mobility)
in 14 of 16 discrepancies. Convery (1977) reported that
I physical therapists do tend to score ADL slightly higher
I than other health professionals. However, in this study,
I
I 2 clients (#2 and #5) had immediate changes in their care
i
i plans as a result of the physical therapy evaluation.
I This would suggest that with this select group, case
managers underestimated clients' functional mobility.
Under-rating of ADL scores by oral interview may be
’ explained as follows : (1) Low expectations by case!
! i
managers for clients who are (a) depressed and poorlyi
! motivated (#2 and #3), and (b) clients beset by frequent;
! ;
I medical illnesses and considered too frail (client #5);!
I I
j (2) Functional capabilities that are not apparent except,
I by performance trial, i.e., ability to independently i
! ambulate stairs which permitted access to the outside
(clients #1 and #6).
37
Another cause for raters' discrepancies may be the
i wide interpretation of terms such as "Independent,"
"Supervised," and "Assisted." Within each of these j
: categories there is a wide range of functional
performance. For example, the time it takes to perform an
activity and the use of equipment to complete a task, are
not considered in grading these levels of performance.
I One who is "Independent," for example, could take an
I extraordinary time to complete an activity, even with
I
j assistive devices. An ADL scale which measures the
I duration and frequency of self-care tasks has been
: reported by Halstead and Hartley (1975) they showed that
I
; validity of time-measured tasks was relatively inaccurate
but that frequency of assistance needed was highly
: accurate and could serve a useful role in further
i
j quantifying and analyzing patients' behavioral patterns.
I Such a time and frequency measurement of ADL could be very
I
useful in care planning for home chore and personal
assistance. In an oral interview, clients may state that i
I an activity is impossible to do when they are actually |
I indicating that the time it takes to complete it makes it
I impractical to do.
The performance evaluation, on the other hand, grades
I
I the individual on completion of the task, regardless of
I
, the time it takes. This could account for the higher
38
functional rating by performance evaluation. Furthermore,
1 the physical therapist is measuring a functional activity
I on a one-time basis. When clients have to perform the
I
' activity frequently, it may be too much of a burden,
especially when fatigue is a factor. In that case,
j clients would be indicating, on an oral interview, that
I they need assistance with a particular activity even
; though they may be able to independently perform that
j activity once or twice a day.
I Walking outdoors showed not only the most frequent
I
j discrepancy in scoring between MSSP's oral interview and
' the performance evaluation (5 of 6 clients differed) but
the discrepancies were not unidirectional. Two of the 5
clients scored lower by the physical therapy evaluation.
Walking outdoors was complicated by many physical and|
: psychological barriers. For example, 5 of the 6 clientsj
; had to use stairs to gain accessibility to the outside. |
I In the performance evaluation, all clients who were able {
I !
1 to ambulate stairs were also able to walk outside. This I
I
was not true with the oral interview. Two clients (#3 and |
i #4), graded as able to ambulate outside by oral interview,I
! i
j were judged unable to ambulate stairs in the same}
j interview even though these clients had stairs to go out j
i of doors. In the physical therapy evaluation, neither of|
these clients could ambulate stairs, even with assistance,!
39
! and were consequently given an "Unable" or "O" score for
I outdoor ambulation. Technically, both of the clients
j could walk indoors so that without the physical barrier of
I
! the stairs, they probably could walk outside also. At
I
: least one client (#4) had a known psychological barrier to
walking outdoors. She was quite secure indoors where she
I
had a well established care routine which she was able to
I control. Out of doors she could not ask for a chair or
1
j the commode which she frequently needed. Therefore she
j was "unable" to walk out of doors for reasons other than
I ability to walk.
Perceptions of Functional Mobility
Two areas of concern which emerged as a result of
!
this study were as follows : (1) Case managers were not
I recognizing effects of orthopedic injuries with
! I
j immobilization, and prolonged bedrest, on muscle and joint i
I restriction and functional immobility; and (2);
I I
; Underestimation, by oral interview, of functional mobility'
! in very frail, highly dependent, and depressed clients.j
' Case managers expected their clients after prolonged]
immobilization by casting (clients #1 and #6), to function|
I
at pre-injury level as soon as casts were removed. Client j
#5, in spite of prolonged bedrest, following a medicalj
crisis, was expected to return to her previous functional
40
level as soon as her medical problems cleared. Prolonged
immobilization, by casting, inevitably leads to temporary
restrictions in motion and strength of the affected part.
Bedrest diminishes cardiovascular responses to standing
which contributed to client #5's dizziness and fainting
episodes. If left untreated, such restrictions become
chronic. Reassessment, or possible referral to
rehabilitation services, in the early stages following
immobilization, is advisable especially with the
chronically disabled elderly.
The second area of concern dealt with the
difficulties in distinguishing physical limitations from
depression and poor motivation (clients #2, #3 and #4).
In these cases, where case managers needed to confirm
psychological problems and to rule out physical
limitations, the physical therapy evaluation was very
i useful. Clients #2 and #3 were found to be able to
^ i
I perform at a higher level than was perceived by oral i
' interview by case management.
41
SUMMARY AND RECOMMENDATIONS
The effect on care planning of a physical therapy
i performance evaluation on frail elderly clients receiving
I
\ case management was investigated. Changes in perceptions
j of case managers about their clients' functional mobility,
I both before and after a physical therapy evaluation, was
; studied. Clients were selected by case managers for this
study on the basis of need for a further opinion on
!
I clients' rehabilitation potential. Several findings and
recommendations were generated from this study and may be
I summarized as follows :
■ Summary of Findings
1. Case managers were able to select, from their
general case loads, a group of Program clients
I who needed further evaluation of their
I functional mobility.
I
j 2. Characteristics of this group of clients
I differed from the general Program client in that
!
; they were older, that they needed more
1
assistance and that they did not live alone as j
did the typical Program client. |
i (a) Majority of study clients were 6 or more
years older than Program client.
42
(b) Study clients needed assistance with a
greater number of basic ADL tasks (5 of 6
clients) than the "typical" Program client.
(c) Only one study client lived alone. Most of
the general Program clients live alone.
3. Degree of disability was more closely related to
functional mobility problems than was age. The
youngest client, in this study, was the most
disabled.
4. Generally study clients were found to be more
functional by performance evaluation than by
oral interviewing (MSSP). As a direct result of
performance evaluation, 2 clients had immediate
changes in care plans to reflect higher ADL.
5. Factors which inhibited referral to
rehabilitation services of study clients by case
managers were as follows: a) Expectations by
case managers that clients would fully
recover, on their own, from injury and
immobilization; b) Clients were too depressed
and poorly motivated to go into rehabilitation;
and c) Clientswere too physically frailto take
advantage of physical therapy services.
43 !
6. Perceptions of case managers were changed after,
performance evaluation, in 5 of the 6 clients in
this study. In all of these cases, the
performance evaluation either confirmed or ruled
out physical limitations as a cause of
dependency.
7. Identification of clients in a case management
system, who can benefit from a physical therapy
(performance) evaluation, has been completed.
This investigation, however, serves only as a
pilot study for establishing a mechanism to
improve client care planning.
Recommendations
1. A sub-assessment or referral for evaluation by
rehabilitation services for clients in a case
management system should be considered for the
following conditions: a) After immobilization,
e.g., casting, of any part of the body following
orthopedic injury; b) After a period of bedrest;
c) In clients with depression or poor motivation
which interferes with accurate assessment of
physical mobility; and d) In clients with very
low and dependent ADL ratings.
44
! 2. Further research is indicated to test criteria
for sub-assessment and referral to
rehabilitation services on the general MSSP
population or any other case management system
1 for frail, chronically disabled, elderly.
I 3. Functional disability, caused by acute and/or
I
chronic disease states, should be considered as
I acceptable criteria for admission to home health
j
agencies. "The right to assessment" should
apply to the homebound, chronically disabled
I elderly, at risk of institutionalization, just
as it does to the acute patient returning home
i from the hospital.
45
REFERENCES
Besdine, R., Gurian, B., Terry, T., and Wettle, T. (1982).
Handbook of geriatric care. Harvard Medical School,
Division on Aging.
Binstock, R.H., and Shanas, E. (1976). In Handbook of
aging and the social sciences, pp. 592-614. New York: D.
Van Nostrand Co.
Brody, E. (June, 1979). Planning for the long-term
support/ care system : The array o f s e rvi c e s to be^
considered, Region III Center for Health Planning, 7
Benjamin Franklin Parkway, Philadelphia, Pennsylvania.
Butler, R.N. (1969). Ageism : Another form of bigotry.
Gerontologist, 9, 243-246.
California Health and Welfare Agency (Submitted by)
(1984). The multipurpose senior services program. Report
to The California State Legislature.
Callahan, J. and Wallack, S. (1981). Reforming the long
term care system, pp. 121-162. Lexington: D.C. Heath and
Company.
Chapman, J., Director, Multipurpose Senior Services
Program, Jewish Family Service of Los Angeles (July 26,
1985). Personal communication, Los Angeles, California.
Convery, F., Minteer, M., Amiel, D., and Connett, K.
(1977). Polyarticular disability: A functional
assessment. Arch Phys Med Rehab 58, 494-499.
Halstead, L., and Hartley, R. (1975). Time care profile :
An evaluation of a new method of assessing ADL dependence.
Arch Phys Med Rehab 56, 110-115.
Kane, R. and Kane, R. (1981). Assessing the elderly: A
practical guide to measurement, pp. 2 5-67, 247-271.
Lexington: D.C. Heath and Company.
Kuriansky, J., Gur land, B., Fleiss, J., and Cowan, D.
i (1976). The assessment of self-care capacity in geriatric
I psychiatric patients. J Clinical Psych 32, 95-102.
46
Libow, L., and Sherman, F. (1981). The core of geriatric
medicine; A guide for students and practitioners, pp. 7-
10. St. Louis: The C.V. Mosby Company.
Parris, R. (1974). Physical therapy and the geriatric
patient in the community. Phys. Ther 54, 18-19.
Pegels, C. (1980). Health care and the elderly, p. 21.
Rockville : An Aspen Publication.
Pollack, W. (1979). Expanding health benefits for the
elderly, p. 17. Washington, D.C.: The Urban Institute.
Sager, A. (1979). Learning the home care needs of the
elderly: Patient, family, and professional views of an
alternative to institutionalization. Waltham : Brandeis
University, Levinson Policy Institute.
Steinberg, R., and Trejo, L. (1984). Front-line
practitioner* s views of long-term care in Los Angeles
County, An interim report of findings, pp. 24-26. Staying
At Home Research Project, Los Angeles : University of
Southern California, Institute for Policy and Program
Development.
47
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48
TABLE 2
FONCTIONAL SCORES OF HOMEBOUND ELDERLY CLIENTS
BY ORAL INTERVIE’ . r f (MSSP) & BY PERFORMANCE EVALUATION
CLIENT
MOBILITY TASK
TRANSFERS
Bad & Chair
MSSP T.T.
3 3
MSSP 3 ; T ■
1 3
"MSSP P.T.
3 3
MSSP
1
P. T..
1
U S S P P.T.
0 1
~^SSP P.T
3 3
Tpilet 3 3 0 3 3 3 0 0 0 0
3 3
Tub/Shovar 1 3 1 1 1 2 0 0 0 0 1 1
AMBULATION
Indoors
3 3 1 3 3 3 . 1 1 0 1 3 3
Outdoors 1 3 0 2 1 : 0 1 0 0 0 1 2
Over 1 Block 0 0 0 0 0 0 0 0 0 0 1 0
Stairs 2
3
0 1 0 0 0 0 0 0 1 3
TOTAL SCORE 13 18 3 13 11 11 3 2 0 2 13 15
CODE
3 = INDEPENDENT
2 = SUPERVISED
1 = ASSISTED
0 = UNABLE
49
TABLE 3
C A R E P L A N C H A N G E S B Y C A S E M A N A G E M E N T
•3HEHAPY E V A L U A T I O N
I M M E D I A T S C H A N G E E F F E C T E D
cLiErrr#
1
2
3
U
F R O M
No r e h a b i l i t a t i o n
No o u t d o o r a m b u l a t i o n
(s t r i c k l y home b o u n d )
No r c h a b i l l a t i o n
No r e h a b i l i t a t i o n
T o t a l b e d d e p e n d a i c e
(supine p o s i tion)
No r e h a b i l i t a t i o n
Ho r e h a b i l i t a t i o n
TO
R e f e r to p h y s i c a l t h e r a p y
B e g i n o u t d o o r a m b u l a t i o n
w i t h a s s i s t a n c e o f A i d e
R e f e r to p h y s i c a l t h e r a p y
R e f e r t o p h y s i c a l t h e r a p y
B e g i n s i t t i n g u p I n c h a i r
R e f e r to p h y s i c a l t h e r a p y
R e f e r to p h y s i c a l t h e r a p y
50
TABLE 4
C H A NGES IN CASE WORKERS' PERCE P T I O N S O F CLIENTS F O R REHA B I L I T A T I O N
SERVICES B E F O R E A N D AFTER PHYSICAL THERAPY EVAL U A T I O N
CLIENT f r
1
BEFORE
"Client would i m p r o v e to
pi d o r level \dien ca-st was
removed"(torn l i g a m e n t s in
k n e e ) .
AFTER .
"She h a s r e s t r i c t i o n s in h e r
k nee which we did n o t pi c k
up" (post-cast removalj*.
2 *. "I7on-nm*mlator. F o r person- "Frailness not that acute,
al care only. Too depres- Much o f h o w I p e r c e i v e d h e r i s
sed & physic ally frail". h o w she p e r c e i v e d herself?.
N o w b e i n g considered f o r a
day care center.
3.
"Poor motivation and marked
depression".
" T was n o t aware t h a t she was
as capable as y o u r test showed".
"Depression and p a s s i v i t y . -
Psycho dynamics h o l d h e r
back".
"If she could get to connode
(after a rehabilitation program)
she m a y n o t n e e d a n i g h t worker".
"Husband could assist her?.
5.
"Too many medical crises.
Too freouent hocoitilizat-
i o n s " .
" D a u ^ t e r ' s anxiety about c l i e n t ’s
tolerance contributes to Mother's
d epen d e n c y ? .
"Would be able to return to "Client's fainting episodes n e w
prior functional level wiien information to m e " .
medical problems cleared".
6.
"When she would come out of
cast we would expect her
to be like o l d self** (fract^
ured (R) w r i s t ) .
P o s sibility o f " b o a r d i n g a bus i s
conditional'— i f client could
overcome fear she could do it".
51
TABLE 5
J Œ Y - J T N D I N G S T N P E R F ORMANCE EVALUATION^WHICH C H A N G E D C A S E
• MANAGERS' PERCEPTION OF CLIENTS' ' FUNCTIONAI. MO B I L I T Y
GLIST'IT § CASE MANAGERS' PERCEPTION
K E Y FINDINGS:
P ERFORMANCE EVALUATION
C l i e n t ' 3 kn e e inj u r y would
i mprove o n its own.
Client could be discharged
from case management in
6 months.
C l i e n t . u n a b l e to f u l l y extend
(R) k n e e ( 10^ co n t r a c t u r e ) .
Generalized weakness b o t h l o w e r
extremities (Fairf-).
L o w cardio-pulmonary endurance-
shortness o f breath after ^
b lock o f walking.
Client n e e d s personal
assistance to get o u t o f
b e d and to ambulate.
Client i s unable, evai with
personal assistance, to
ambulate stairs i n o r d e r
to go outside.
I h d e p é n d œ t l y able to get o u t o f
b e d and to ambulate i n room.
Able to ambulate stairs b y h o l d i n g
rail with both h a n d s - n e e d a s s i s t
ance o n l y to carry w a l k e r u p and
down steps.
Can ambulate with walker, o n sidewalk,
with supervision, about 30 feet.
difflit i s very depressed
o v e r family relationship
and is using dependency
to enlist more*help.
Client i s capable o f t r a n s f e r r i n g
into & o u t o f tub and w a l k i n g with
walker, both with o n l y sûpèrvision-
no physical assistance necessary.
Client i s very depressed
and passive. She has
ability to function at
h i ^ e r level. Psycho
dynamics hold h e r back.
No significant finding which c h a n g e d
case manager's perceptions.
Walking not considered as
possible - too dependent.
Two people needed to assist
client to sit up on edge
o f b e d & to transfer to
chair.
Note: Daughter was keeping
Mot h e r in bed to avoid
fainting episodes (no
u p r i ^ t activity).
Client can stand with assistance and
walk, i n walker, with 2 p e r s o n s f o r
stand-by assistance, about 10 feet.
Client can sit over edge o f bed, w i t h
out fainting, for several minutes.
Client requires help o f son. Client i s Independent, with cane, on
o r any other person, to
ambulate stairs (outside).
Needs assistance to walk ,
outside because o f fear o f
falling.
stairs (uses wall to l e a n against
for safety).
Client is able to walk o u t s i d e with
supervision (no assistance n e c e s
sary) but is limited b y b a c k pa i n
to approximately 50 feet.
52
APPENDIX A
J
CLIENT DESCRIPTIONS: Following is a brief narrative about
each of the six clients, which supplements information in
Table 1:
Client #1 was an 88 year old female who lived alone
in a lower apartment. She became homebound after
falling and injuring her right knee, sustaining torn
ligaments, 3 months prior to being referred as a
subject for this study. She was put in a cast to
allow ligaments to heal. She came out of cast 6
weeks after her fall. She had generalized arthritis,
including spine, with pain in lower back. Her
cognition was excellent. Her attitude was "life is
difficult now" since sustaining injury to the knee.
She had heart disease and took heart medication. She
used a walker in the morning on arising, and switched
to a cane for the rest of the day. She had a home
health aide 3 times per week for personal care
(bathing and grooming) and to assist her with
ambulation. She had a home chore worker 15 hours a !
i
week. I
Client #2 was a 92 year old female who lived in a ,
board and care home. She was described by her case ;
worker as being markedly depressed, having a history
j
of depresssion and a suicide attempt. She has been j
54
■homebound for 2 years after sustaining a hip
fracture. She was hospitalized 2 months ago with
acute esophagitis and pneumonia. She became
incontinent of bladder and bowel since pneumonia.
Her cognition was good. Her attitude was one of
resignation to her condition. Her functional
mobility was described as very limited at this time.
She stayed in bed most of the day. She needed
assistance to get up out of bed and to ambulate a few
feet in her room with a walker. She had a home health
aide for personal care with bathing, laundry,
changing wet linen, and walking, three times a week,
8 hours a day. Client saw herself as very disabled
with "two broken legs".
Client #3 was a 92 year old female living in a board
and care home. She became homebound after suffering
a left CVA, causing right hemiparesis, 1 1/2 years
prior to becoming a client. She was described by her
case worker as being very dependent, depressed and |
1
poorly motivated. She had resided in three different|
I
board and care homes after the death of one of her <
daughters. Her cognition was normal. Her attitude i
changed from cooperative to indifferent during ^
periods of depression. Her medical history included
55
severe heart disease, for which she was medicated,
and a low cardiovascular endurance. She was able to
walk, independently in room, with a walker but only
up to 30 feet in hallway limited by shortness of
breath. She had a personal care aide 3 times a week ,
to assist with bathing, dressing, ambulation and |
i
assisting with medical appointments. i
Client #4 is a woman, 78 years of age, who lived in
I
an apartment with her husband and a live-in |
I
attendant. She became homebound 4 years before ;
becoming a client after suffering a series of strokes .
I
which left her with (R) hemiplegia. She wore a brace I
I
on her right leg and used a quad cane and a i
wheelchair. She required assistance for all ADL. She i
I
used a commode in her bedroom. Her cognition was i
slightly impaired. She was described by her case j
worker very dependent, passive and functioning below
a level for which she was capable. She was very
fearful of falling. Client had heart disease, high |
I
I
blood pressure and a history of dizziness. She took \
I
prescription medicine for all of these conditions. ;
Client sat in a chair most of the day. She walked '
only when attendant assisted her. !
56
Client #5 was a 90 year old female who lived in an
apartment with her daughter who was her primary
caretaker. Client had been homebound for several
months secondary to general medical problems and a
fear of walking (fear of falling and breaking a hip).
Client had cardiovascular disease, and a history of
cardiac arrhythmias and unstable blood pressure. She
became totally bedbound after contracting shingles on
the (R) side of her neck and head. Mother and
daughter had a mutual dependency relationship.
Daughter anxious about her mother's condition. She
feared that her mother would faint if she was allowed
to sit up. Consequently, daughter kept her mother
bedfast, in a supine position, which was not
objectional to client. Cognition appeared to be
within normal limits. She was hard of hearing.|
«
Daughter tended to answer for her. She claimed her j
mother wanted to be able to walk like before, but she !
stated mother must have 2 persons with her, in case I
of fainting. Medical doctor stated that client's,
heart rate and blood pressure were stable but thatI
I
she probably had ortho-static hypotension (poor bloodi
pressure response to upright position) which was|
characteristic of persons who had been on prolonged
bedrest. Client was using bed pan. Besides full
57
time care by daughter, she had a home health aide 2
times per week for 2 hours each time.
Client #6 was an 82 year old lady living in a
downstair apartment with an emotionally disabled son.
Client became homebound after falling and fracturing
her (R) wrist, 7 months ago. Prior to her wrist
fracture, she had fractured her (R) shoulder which
left her with residual weakness in arm. The
disability made it too difficult to board a bus which
was her main form of independence. Other medical
problems included hypertension, diabetes, spinal
discogenic disease, and cataracts. After her wrist
fracture, her medical problems became more pronounced
and she lost the ability to ambulate independently.
She became highly dependent on son for help.
Client's cognition was excellent. Her attitude was
good as she was coping with her situation while
maintaining a hopeful outlook. She walked
independently indoors but relief on son for all
outdoor ambulation. She was very limited by low back
pain during walking. She had an aide for personal
care 2 times a week and a chore person 1 time a week.
58
r-
APPENDIX B
59
MSSP CLIENT INFORMATION
CLISNT’o NAME!
CLIENT'S ADDRESS!
CLIENT'S TELEPHONE NUMBER:
MEDICAL DOCTOR'S NAME:
DOCTOR'S TELEPHONE NUMBER:__________
TREAT2{ENT DIAGNOSIS :_________________
ONSET :__________________
PERTINENT MEDICAL/SURGICAL HISTORY:,
PRECAUTIONS :
ESTIICATION 0? RESTORATIVE POTENTIAL
*CLIENT CONSENTS TO PARTICIPATE ___
MSSP CASE WORKER:,
DATE;
cate j
♦Human subjects consent i'orm lor participating clients will
be brought by principle investigator.
60
APPENDIX C
61
HUMAN SUBJECTS CONSENT FORM
SCHOOL OF GERONTOLOGY, UNIVERSITY OF SOUTHERN CALIFORNIA
CLIENT*S NAME:_________________________________________
ADDRESS:__________________________________ TELEPHONE:
THE PURPOSE OF THIS STUDY IS TO DO A PERFORMANCE PHYSICAL THERAPY
EVALUATION ON YOU AND COMPARE THE FINDINGS WITH MSSP*S ORAL
QUESTIONAIRRE DONE PREVIOUSLY ON YOU.
AS A PARTICIPANT, YOU WILL BE ŒEVEN A PHYSICAL THERAPY EVALUATION
3Y A PROFESSIONAL PHYSICAL THERAPIST. YOU WILL BE TESTED FOR THE
FOLLOWING: 1. JOINT MOTION; 2. MUSCLE STRENGTH; 3. ABILITY TO DO
FUNCTIONAL TASKS SUCH AS SITTING AND STANDING UP, GOING IN AND OUT
OF A TUB OR SHOWER(DRY), WALKING IN- AND OUT-OF-DOORS, STAIR CLIMB
ING; 4. BALANCE CONTROL; 5. SENSORY PROCESSES INCLUDING PAIN; AND
6. ENDURANCE. TOTAL TEST TIME WILL TAKE ONE HOUR.
THERE ARE NO KNOWN HAZARDS ASSOCIATED WITH THESE TESTS. THE PHYS
ICAL THERAPIST WILL OFFER YOU ASSISTANCE AS NEEDED FOR YOUR SAFETY.
YOU WILL BE ASKED TO PERFORM ONLY UP TO YOUR ABILITY. YOU MAY BE ASKED
TO TRY TO USE ASSISTIVE EQUIPMENT WHICH WILL BE PROVIDED BY THE
PHYSICAL THERAPIST.
YOU MAY WITHDRAW FROM THIS STUDY AT ANY TIME WITHOUT JEOPARDIZING
YDUR ELIGIBIIITY FOR SERVICES WHICH YOU ARE NOW RECEIVING OR WILL
BE RECEIVING FROM MSSP.
INFORMATION GAINED ABOUT YOU FROM THIS STUDY WILL BE DISCUSSED
CONFIDENTIALLY WITH YOUR CASE WORKER FROM MSSP. ALL REPORTS AND
PUBLICATIONS FROM THIS STUDY WILL NOT USE YOUR NAME.
POTENTIAL BENEFIT TO YOU WILL BE IN THE FORM OF ADDITIONAL INFORM
ATION TO YOUR CASE WORKER TO USE IN YOUR CARE PLANNING. POTENTIAL BENE
FIT TO SOCIETY IS AN IMPROVED ASSESSMENT OF HOMEBOUND CLIENTS.
IN THE EVENT OF AN ACCIDENTAL OR MEDICAL EMERGENCY, THE PHYSICAL THERA
PIST WILL RENDER FIRST AID THEN CALL YOUR DOCTOR OR PARAMEDICS, WHICH
EVER IS INDICATED.
all QUESTIONS I HAVE CONCERNING THIS. STUDY HAVE BEEN FULLY ANSWERED.
IF I HAVE FURTHER QUESTIONS, I SHOULD CONTACT:
RON GREENBERG, R.P.T. AT (213)935-6360
CLIENT SIGNATURE:___________________________________ DATE:______________
I HAVE EXPLAINED THE NATURE OF THIS STUDY TO THE CLIENT. I HAVE
ANSWERED ALL QUESTIONS ABOUT THIS STUDY ASKED BY THE NAMED CLIENT
OR BY RESPONSIBLE CONCERNED PERSONS ASKING ON BEHALF OF THIS CLIENT.
I HEREBY WITNESS THE ROREGOING SIGNATURE
(INVESTIGATOR) (DATE)
APPENDIX D
63
PHYSICAL THERAPY CARE PLANNING
EVALUATION
DATE:
NAME;
BIHTHDATE:
MEDICATIONS (INCLUDE CONDITIONS):
COGNITION-ATTITUDE :
VISION: HEARING :
CARDIOPULMONARY ENDURANCE:.
SENSORY PROCESSES:_________
SPEECH :
SOCIAL/ENVIRONMENTAL:
EQUIPMENT/SUPPLIES : IN HOME-.
NEEDED-
RANGE OE MOTION, STRENGTH, AND FUNCTIONAL MOBILITY; (See
separate forms)
PROBLEMS (Numbered) GOALS (Relate to problems)
Patient's goals
TREATMENT PLAN RECOMI-IENDATIONS
Short term (Expected time)
Long term
P.T. Signature:
64
APPENDIX E
65
PHYSICAL THERAPY EVALUATION
PASSIVE RANGE OF MOTION & MUSCLE STRENGTH
CODE
STRENGTH
N - Normal
G — Good
P - Pair
P - Poor
T - Trace
0 - Zero
HIP
FLEXION
PASSIVE ROM
(PAIN LIMITED*)
-iR) (1*)
STRENGTH
iEi 111
COMMENTS
EXTENSION
ABDUCTION
ADDUCTION
EXTERNAL ROTATION
INTERNAL ROTATION
STRAIGHT LEG RAISE
KNEE
FLEXION
HYPER-EXTENSION
ANKLE
DORSIFLEXION
PLANTAR'LEXION
SHOULDER
FLEXION
ABDUCTION
EXTENSION
ELBOW
FLEXION
EXTENSION
WRIST
FLEXION
EXTENSION
FINGER
FLEXION
EXTENSION
66
APPENDIX F
67
PHYSICAL THERAPY PERFORMANCE
EVALUATION
CODES :
FUNCTIONAL LEVEL
I - Independent
S - Supervised
03 - Contact guarded
MIN - Minimum assistance
( T25%)
MOD - Moderate assistance
(25-50#)
MAX - Maximum assistance
( > 5 0%)
FUNCTIONAL TASKS
EQUIPMENT
PUW - Pick-up Walker
FWW - Front-wheel Walker
CR - Crutch
C - Cane
QC - Quad Cane
WC - Wheelchair
OB - Grab Bar
HR - Handrail
P - Furniture
CODES
FUNCTIONAL EQUIPMENT
LEVEL USED COMMENT:
RECUMBENT
Roll On Side
Scoot
TRANSFERS -
TO BED
Sit To Supine
Supine To Sit
Sit To Stand
TO CHAIR (STANDARD)
Sit To Stan:
TO TOILET
Stand To Sit
Sit to Stand
TO TUB/SHO.vER (Tub bath, tub shower, stall shower)
(please circle)
Steps In _
Sits in tub, on tub chair ___ ____ _
(cirle)
Stands From Sit __
Steos Out _
WALKING
Indoors
Outdoors
STAIRS
68
APPENDIX G
1_____________________________ 69
FEÎSICIL THERAPY CARE PLANNING
EVALUATION
! CLIENT’S NAME:
F.T. EVALUATION DATE:
PROBLEM LIST
1.
2*
3.
G O A L S
SHORT TERM:
LONG TERM:
TREATMENT PLAN RECOMMENDATIONS
1.
2.
3.
Signatiire:,
DATE
RON GREENBERG, RPT
MASTER'S PROJECT, GERONTOLOGY
fU. S.C.)
70
APPENDIX H
71
INITIAL ASSESSMENT
OF MSSP CLIENT
PSYCHG-SOCIAL STATUS
^ Client Name:
Last (Family) First Middle
4 MSSP N um ber O O O O
4 Date of Assessment: O O O O O O
Mo Day Year
^ Client Address:
( Optional Use)
# Telephone: C U C j l Z ] - O O O - O O O O
( Optional )
Special QC and Subsequent Use Codes:
a The Diamond symbol denotes a critical field for data entry which requires quality control
^ caution and review at the local level.
« The Asterisk symbol denotes a field which is always optional. These items are not con
sidered essential to the research effort. However, such items might be very valuable to
the case management team for describing unique client circumstances. Optional items will
be printed on the assessment summary report.
The symbol indicates that this item is required only for the first administration of the
revised assessment instrument. Such items maybe skipped on subsequent administrations
of this form.
Revised: 6/30/82
72
Mobility Functioning Information
STAIR CLIMBING:
♦
I ♦
;
U
♦ 4 .
♦ 5 .
♦ 6.
Do you climb stairs?
Yes No ^
Are you able to climb stairs?
1 Yes... unassisted]
2 Yes...assisted Skip to Question 6
3 No....unable j
Does anyone help you climb stairs?
Yes ^ No a r Skip to Question 6
Who (what) helps you with stair climbing? Circle all that apply and give number
1 Spouse 6 Grandson - 10 Other Person
2 7 Granddaughter
3
..
Sister 8 Friend/Neighbor relationship, #
4 S nn 9 Other Relative 11 Formal Support
5 Daughter 12 Special Equipment
Do you get help from someone when you need it with stairs climbing?
I Always 2 Usually 3 Sometimes 4 Rarely
Does the client need (more) help with stair climbing?
No Yes... Describe
* 7. Client comments; * 8. Worker comments:
73
WALKING:
♦ 1-
♦ 2-
♦ 2-
♦ " •
♦ 5 -
Do you ever go outdoors for a walk of more than one city block?
Yes No
Do you walk by yourself? (Probe: Does anyone help you while you walk? Do you use anything
for support?)
Circle the numbers corresponding to the categories that describe client’s walking status (a)
outdoors and (b) indoors.
4 2(a)
OUTDOORS
4 2 (b )
INDOORS Record the codes which best describe respondent’ s walking status
(Someone who is wheelchair bound is included in the mechanical suppora cawgoriesJ
1 Walks without help from another person or any mechanical device.
2 Walks with help of mechanical supports. (No personal help.)
3 Walks with the assistance of another person. (No mechanical help)
4 Walks with help of both mechanical and personal assistance
5 Does not walk, (possibly carried)
6 Does not walk. (Is bed bound)
Who helps you with walking? Circle all that apply and give number
0 No one helps...Skip to question 5.
I Spouse 6 G ran d co n ------_
10 Other Person
2
R ro rh er 7 G ra n d d a u g h te r ,
3 S ister 8 F rie n d /N e ig h h o r ,
relationship, #
4 Son _ 9 O th e r R elativ e _
11 Formal Support
5 Daughter
Do you get help from someone when you need it with walking?
1 Always 2 Usually 3 Sometimes 4 Rarely
Does the client need (more) help with walking?
No Yes...Describe
* 6. Client comments: * 7. Worker comments:
74
TRANSFER: Getting out of bed, chairs, etc.
^ 1. Do you get out of bed?
Yes i No w r Skip to Question 8
4 2. Do you move in or out of bed and chairs without any kind of assistance ?
No i Yes w Skip to Question 8
4 3. Do you use a walker, cane, furniture or any other object as a support to get into or out of chairs
or bed? (But not support from others)
No i Yes Skip to Question 8
4 4. Does someone give you support in getting into or out of chairs and bed? (Not lifting or
carrying)
No i Yes — ». — » — » — »
4 5. Are you lifted from one place to another ^
♦ 6 .
No . Comment Required ^ Yes | |
Who (what) helps you with transferring? Circle all that apply and give number
1 Spouse 6 G ra n d so n 10 Other Person
2
R rn th er 7 Granddaughter-
3
S ister 8 F rie n d /N e ig h h o r relationship, #
4 S on 9 O th e r R elativ e
• II Formal Support
5 D a u g h te r 12 Special Equipment
4 7. Do you get help from someone when you need it with transfer?
1 Always 2 Usually 3 Sometimes 4 Rarely
4 8. Does the client need (more) help with transfer?
No Yes...Describe
9. Client comments: * 10. Worker comments:
75
BATHING:
4 1. Do you bathe without any assistance? (It could be a tub bath, sponge bath, or a shower.)
1 YesJ#" Skip to Question 5.
3 Does not bathe Skip to Question 5.
2 No i
4 2. Except for help in washing one part of your body (e.g., back of leg, back, etc.) do you bathe
yourself?
i No...Implies more than minimal bathing assistance Yes 1
♦ 3.
♦ 4 .
♦ 5.
Who (what) helps you with bathing? Circle all that apply and give number
1 Spouse 6 Grandson -----
10 Other Person i
7 Rrnth^r 7 Granddaughter
3 Sister 8 Friend/N eighhor ,
relationship, #
4 Son_____ 9 O ther Relative _
11 Formal Support
5 Daughter 12 Special Equipment
Do you get help from someone when you need it with bathing?
1 Always 2 Usually 3 Sometimes 4 Rarely
Does the client need (more) help with bathing?
No Yes... Describe
4^ 6. Client comments: * 7. Worker comments:
76
TOILETING;
♦ 1 -
♦ 2.
♦ 3 .
4 4 .
♦ 5 .
♦ 6 .
Does anyone help you when you go to the toilet (room) (e.g. getting to!from toilet room, on/off
toilet, arranging clothes, cleaning up)?
1 Yes I 2 No 1 3 Does not use a toilet (room) [
Do you use a bedpan or commode?
1 N o a r Skip to Question 4.
2 Only at night i 3 More than night use [
Does anyone help you with your bedpan or commode?
Yes 1 No I
Who (what) helps you with toileting? Circle ail that apply and give number
0 No one helps...Skip to question 6.
1 Spouse 6 G ra n d so n
10 Other Person 1
2
Rrnth#»r 7 G ra n d d a u g h te r
3 S iste r 8 F rie n d /N e ig h h o r relationship, #
4 S nn 9
O th e r R elativ e
11 Formal Support
5 D a u g h te r 12 Special Equipment
Do you get help from someone when you need it with toileting ?
I Always 2 Usually 3 Sometimes 4 Rarely
Does the client need (more) help with toileting?
No Yes... Describe
* 7. Client comments: * 8. Worker comments:
77
APPENDIX I
78
J
INTERVIEW OF MSSP CASE MANAGER
TODAY'S DATE:____________________
CLIENT'S NAME:___________________________
CASE MANAGER'S NAME]____________________
DATE 0? CLIENT'S LAST MSSP EVALUATION
DATE OF PHYSICAL THERAPY EVALUATION:
INSTRUCTIONS: The interviewer will ask the case manager the
jiOllowing questions in order to identify key iactors which
were used to determine the following: (1) Case worker's
perception o: client's functional mobility status; (2) How
needs for assistance were identified; (3) How care plan was
established (services selected); (4) Purpose of each service;
'(5) Case worker's perception of restorative potential of
Iclient; (6) Determination for rehabilitation consultation; and
j(7) Need for changes in care plan after P.T. evaluation and
^discussion with therapist.
. 1. From your assessment, what did you perceive as client's
functional mobility status (refer to coded answers in
"Assessment") for the following mobility items?:
a, stair climbing________
b. walking
c. need for walking aids,
d. transfer ability ]
2. Did you think client needed help?:______ . .-rith what?
How did you determine client's need for (more) nelp
with the following?:
a. stair climbing_______________________________________
b. walking
c. need for walking aids,
d. transfer ability '
Nhat services did you include in the care plan in ref
erence to above needs?: _______
5. .fhat was the purpose of each type of service given?
6. Did you see any possibility o*’ Improvement in client's
functional status (independence) wnen you assigned
help?;________, How?;________________________________________
7. Nas your choice of services made in order to maintain
client's functional status or with expectations of im-
p movement?___________________________________________________
79
INTERVIEW -cont'd-
8 Did you consider rehabilitation services for your client?
___________. Why?______________________________________________
INSTRUCTIONS; At this point in interview, Physical Therapist
will discuss the results of P.T. Performance Evaluation, how
it compared with case workers "Assessment", P.T.'s goals for
client(perception of potential for improvement), and recom
mendations for rehabilitation intervention with length of
program and objectives.
9. Do you see reasons why the client could not perform-
at the level suggested by the P.T. Evaluation?;________
10. Do you think the goals established by the physical ther
apist are attainable?:
11. Does this new information in any way change your concept
of the client's care plan?________. In what way?;_______
12. Why did you chose this client for this research project?;
****************************
80
n
APPENDIX J
81
THE VISITING NURSE ASSOCIATION OF LOS ANGELES, INC.
PHYSICAL THERAPY EVALUATION-REEVALUATION VISIT
D I n i t i a l O Interim O Discharge
TREATMENT DX
SURGERY----
ONSET.
DATE _
OTHER PERTINENT MEDICAL/SURGICAL INFORMATION
DIET.
OOGNlTION-ATTITUDE:
VISION: HEARING: SPEECH:
CARDIO-PULMONARY ENDURANCE:
SENSORY PROCESSES:
SKELETAL-ROM:
NEUROMUSCULAR:
FUNCTIONAL ABILITIES:
Recumbent
Come to S i tt i n g
S i t t i n g
Prior Activity______ ___
Balance
T ransfers
Gait
Changes since beginning of b i l l i n g
THIS PATIENT IS HOMEBOUNO BECAUSE: (Medicare, Medi-Cal).
SOCIAL/ENVIRONMENTAL:
EQUIPMENT/SUPPLIES: deeded O
Ordered O
In-Home O
REFER PATIENT TO: NURS OT. SPEECH RD. MSW HHA HMKR VOI HOSPICE OTHER.
DATE SIGNATURE TITLE
PATIENT NAME M R. #
8 2
PHYSICAL THERAPY EVALUATION-REEVALUATION VISIT Page tw o
PROBLEMS (numbered)
GOALS ( r e l a t e to problems)
Patient Goals
Short Term
Long Term
TREATMENT PLAN (Interventions, modalities to coincide with
problems and goals)
Progressive rehabilitation program to Include:
PT Frequency
MEDI-CAL TAR INFORMATION
Name of Medi-Cal MO Consult.
Verbal Authorization #_____
Effective Oates:
Continuation Oates:
From.
From
To.
To
Date T . C .
# V i s i t s _
# Visits-
# Visits-
# Visits-
Discipline
Discipline .
Discipline
Discipline .
PHYSICAL THERAPY ACTIVITIES PERFORMED THIS VISIT:
REHABILITATION POTENTIAL: EXCELLENT □ GOOD □ FAIR Q POOR □ EXPECTED DURATION OF TREATMENT.
DISCHARGE PLANS & HOME PROGRAM: REASON FOR DISCHARGE:
TIME: FROM TO. SOURCE OF FEE, RETURN HV DATE
DATE SIGNATURE TITLE
PATIENT NAME M R. #
83
APPENDIX K
84
_J
^IGIBILTTY GRTTEIHA FOR CASE
(lRrLTI'’ iri?OoR 3ERI0R 3ERVIGEG PROGRM!)
Eligibility critcrir.. for client:: to receive case neiiagenent by
HoGf are as follows:
1. 65 ycrrs of age or over.
2. Currently eligible for fiediceid (l;-±i-Ga3).
3» Currently ccrtlfi- J or certifiat)le'"-ror institutionalisation
in a skilled nursing facility (Gill) or an intermediate care
facility (IC"%
Cortiflability determination is made by 1433? site- stafbased upon
licdi-CaJ- criteria governing placement into such institutions.
Essenticlly the client must bo in frail condition, requiring
assistance in order to manage at home. Tliesc are clients who would
be in danger of institutionalisation without MS.3P services.
85
APPENDIX L
86
DATA SHEET
COMPARISON OF MSSP AND PHYSICAL THERAPY EVALUATIONS
NAME;
EVALUATION DATE: MSSP____________ ; P. T..
FUNCTIONAL L i m L EQUIPMENT COMMENTS
MOBILITY TASK MSSP P.T. MSSP P.T. MSSP P.T.
STAIR CLIMBING ____ ____ ____ ____
WALKING INDOORS
" OUTDOORS
MORE THAN 1 BLOCK
TRANSFERS
OUT OF BED
OUT OF CHAIR
BATHING
TUB
SHOWER
MORE HELP NEEDED
TOILET
ADDITIONAL COMMENTS/FACTORS:
87

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Asset Metadata

Creator Greenberg, Ronald Stephen (author)

Core Title Effect of physical theraphy evaluation on care planning in frail elderly receiving case management

Degree Master of Science

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Health and Environmental Sciences,OAI-PMH Harvest,Social Sciences

Format application/pdf (imt)

Language English

Contributor Digitized by ProQuest (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c37-407582

Unique identifier UC11658649

Identifier EP58916.pdf (filename),usctheses-c37-407582 (legacy record id)

Legacy Identifier EP58916.pdf

Dmrecord 407582

Document Type Thesis

Format application/pdf (imt)

Rights Greenberg, Ronald Stephen

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA