Catastrophic Impairment Designated Assessment Centre ...

[Pages:31]CATASTROPHIC IMPAIRMENT DESIGNATED ASSESSMENT CENTRE

ASSESSMENT GUIDELINES

A guide to conducting catastrophic impairment DAC assessments

October 2001

Table of Contents

PART 1 1.1 1.2

1.3 1.4 1.5 1.6

INTRODUCTION ................................................................................. 1-1

Overview ................................................................................................ 1-1

Purpose of Catastrophic Impairment Assessment ........................... 1-1

Definition of Catastrophic Impairment ............................................... 1-2

Causation .............................................................................................. 1-4

SABS Terminology .............................................................................. 1-4

Special Authorization ........................................................................... 1-4

PART 2 2.1 2.2 2.2.1

2.2.2 2.2.3 2.2.4

DAC RESOURCES ............................................................................ 2-1

Physical Resources ............................................................................. 2-1

Human Resources ................................................................................ 2-1

Case Co-ordination ............................................................................. 2-2

Core Team ............................................................................................ 2-4

On-Call Team ........................................................................................ 2-5

Paediatric Authorization ...................................................................... 2-6

PART 3 3.1 3.2

INTAKE PROCESS ............................................................................ 3-2

Objectives ............................................................................................. 3-2

Intake Steps .......................................................................................... 3-3

PART 4 4.1 4.2 4.3

4.4

4.5

4.6

4.7 4.8

ASSESSMENT PROCESS ............................................................... 4-1

Introduction ............................................................................................ 4-1

SABS Catastrophic Impairment Definition Clauses (a) to (d) ........ 4-1

SABS Catastrophic Impairment Definition Subclause (e) (i) GCS ................................................................................................... 4-1

SABS Catastrophic Impairment Definition Subclause (e) (ii) GOS ................................................................................................... 4-2

SABS Catastrophic Impairment Definition Clause (f) - 55% Whole

Person ................................................................................................... 4-2

SABS Catastrophic Impairment Definition Clause (g) - Mental &

Behavioural Disorders ......................................................................... 4-3

Paediatric Catastrophic Impairment Assessment Process ............ 4-3

Determination of Catastrophic Impairment Status ........................... 4-4

PART 5 5.1 5.2

CAT DAC REPORTS ......................................................................... 5-1

Clinical Co-ordinator Reporting Checklist ......................................... 5-1

Standard Report Format ..................................................................... 5-1

Appendix A

CAT DAC Referral Document Checklist .......................................... A-1

Appendix B

Standard Referral Confirmation Letter .............................................. B-1

Appendix C

GOS Background Information ............................................................ C-1

Appendix D

Standard Report Cover Sheet ........................................................... D-1

PART 1

INTRODUCTION

1.1 Overview

This guide is intended for use by the Catastrophic Impairment Designated Assessment Centres (CAT DACs) under the Statutory Accident Benefits Schedule1 (SABS) in the assessment of catastrophic impairments.

Section 40 of the SABS outlines the process for:

C

application for catastrophic status

C

insurer response

C

assessment and report by a DAC

C

determination of catastrophic impairment.

In the event of a discrepancy between this Guide and the SABS, the SABS shall prevail.

This guide outlines the process for conducting CAT DACs and has been developed with extensive consultation and consensus reached by practice experts. It presents a structured approach to performing CAT DAC assessments, and is designed to achieve the following objectives:

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To be consistent with the SABS.

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To ensure DACs follow a common assessment approach and standard.

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To assist DACs in producing reports that are useful to the parties in resolving

their dispute.

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To provide a structured reporting format that is comprehensive and includes well-

supported conclusions.

When the DAC deviates from this guide, an explanation should be noted in the report. Although CAT DAC processes must conform to the SABS and the requirements of this guide, it is the responsibility of each clinician involved in the assessment to use his/her own clinical judgment in planning the assessment and interpreting the assessment outcome.

1.2 Purpose of Catastrophic Impairment Assessment

Bill 59 includes a definition of catastrophic impairment. Claimants with injuries meeting this definition may have access to a higher level of benefits for medical and rehabilitation goods and services, attendant care, and case management. A CAT DAC assessment will determine whether the claimant is entitled to this higher limit, but will not make a determination as to whether a specific benefit is reasonable and necessary. Any dispute involving this reasonable and necessary test may require a Medical/Rehabilitation and/or an Attendant Care DAC assessment to assist in resolving the dispute in accordance with the SABS.

1 A regulation under the Insurance Act, for accidents occurring on or after November 1, 1996 1-1

The CAT DAC assessment may be initiated in one of two ways:

1) A claimant applies to the insurer for catastrophic status, the insurer denies this request, and the claimant responds by requesting a CAT DAC.

or

2) A claimant applies to the insurer for catastrophic status, and the insurer requests a CAT DAC assessment prior to providing a response to the claimant.

The application for catastrophic impairment determination will state the reasons, according to the treating practitioner completing the application, why his/her patient meets the definition. Factors such as an inadequately completed form or the referring practitioner's apparent lack of understanding of the catastrophic criteria, should not prevent a DAC from conducting the assessment. As well, these factors should not limit the CAT DAC assessment to exploring only the impairment(s) identified in the application. It is the CAT DAC's responsibility to ensure that a comprehensive assessment of each claimant's impairment(s) is conducted to determine if the impairment(s) qualifies as catastrophic.

This principle should not, however, open the door to inefficient assessments that `over assess' the claimant. Accordingly, the intake process and assessment protocols have been designed to focus the assessment appropriately and, where possible, to `stage' assessments so that only necessary investigations are undertaken. In planning and undertaking its assessment, the CAT DAC must balance the need for the assessment to be timely, impartial, comprehensive, and cost-effective.

1.3 Definition of Catastrophic Impairment

According to SABS Subsection 40 (1):

"An insured person who sustains an impairment as a result of an accident may apply to the insurer for a determination of whether the impairment is a catastrophic impairment."

And SABS Subsection 43 (8) states:

"If the assessment is required under Section 40 to determine whether an impairment is a catastrophic impairment, the report shall include a statement of whether, in the opinion of the person or persons who conducted the assessment, the impairment is a catastrophic impairment."

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According to SABS Subsection 2 (1):

"In this Regulation, "catastrophic impairment" means,

(a) paraplegia or quadriplegia,

(b) amputation or other impairment causing the total and permanent loss of use of both arms,

(c) amputation or other impairment causing the total and permanent loss of use of both an arm and a leg,

(d) total loss of vision in both eyes,

(e) brain impairment that, in respect of an accident, results in,

(i) a score of 9 or less on the Glasgow Coma Scale, as published in Jennett, B. and Teasdale, G., Management of Head Injuries, Contemporary Neurology Series, Volume 20, F.A. Davis Company, Philadelphia, 1981, according to a test administered within a reasonable period of time after the accident by a person trained for that purpose, or

(ii) a score of 2 (vegetative) or 3 (severe disability) on the Glasgow Outcome Scale, as published in Jennett, B. and Bond, M., Assessment of Outcome After Severe Brain Damage, Lancet i:480, 1975, according to a test administered more than six months after the accident by a person trained for that purpose,

(f) subject to subsections (2) and (3), any impairment or combination of impairments that, in accordance with the American Medical Association's Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in 55 percent or more impairment of the whole person, or

(g) subject to subsections (2) and (3), any impairment that, in accordance with the American Medical Association's Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in a class 4 impairment (marked impairment) or class 5 impairment (extreme impairment) due to mental or behavioural disorder;"

Also, according to SABS Subsection 2 (2):

"Clauses (f) and (g) of the definition of "catastrophic impairment" in subsection (1) do not apply in respect of an insured person who sustains an impairment as a result of an accident unless,

(a) the insured person's health practitioner states in writing that the insured person's condition has stabilized and is not likely to improve with treatment; or

(b) three years have elapsed since the accident."

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And SABS Subsection 2 (3):

"For the purpose of clauses (f) and (g) of the definition of "catastrophic impairment" in subsection (1), an impairment that is sustained by an insured person but is not listed in the American Medical Association's Guides to the Evaluation of Permanent Impairment, 4th edition, 1993 shall be deemed to be the impairment that is listed in that document and that is most analogous to the impairment sustained by the insured person."

NB: CAT DACs are directed to specific clauses of the SABS catastrophic impairment criteria that restrict rendering a decision until certain conditions are met. Application of criteria e) ii Glasgow Outcome Scale (GOS) is subject to the condition that the test be administered "more than six months after the accident." Criteria f) 55% Whole Person, and g) Mental and Behavioural Disorders, can only be applied if the "insured person's condition has stabilized and is not likely to improve with treatment" or "three years have elapsed since the accident." DACs should note that these conditions do not apply to any of the other catastrophic impairment criteria. When applying criteria e) ii., f), or g) and the relevant conditions are not met, the DAC should clearly state this in the report.

1.4 Causation

CAT DAC assessors must comment on `causation' and are directed to the specific SABS clauses regarding catastrophic impairment outlined above. In addition, assessors should note that according to the SABS [Subsection 2 (1)] accident means:

"an incident in which the use or operation of an automobile directly causes an impairment.."

1.5 SABS Terminology

This guide will not provide interpretation of any SABS terminology, including the definition of catastrophic impairment. It is the responsibility of the CAT DAC assessor(s) to use his/her own clinical judgment in arriving at conclusions and to support these conclusions in a well-documented report.

1.6 Special Authorization

The only special authorization under the Catastrophic Impairment Designated Assessment Centres is for paediatric claimants. Any CAT DAC wishing to conduct assessments on children must have a speciality designation to do so. Although the SABS does not define `child', for the purposes of catastrophic impairment in CAT DACs, a child may be considered to be any claimant who on the day of the accident was 16 years of age or less2.

2 If the claimant is greater than 16 years of age at the time of application, the CAT DAC must still bring in its Core Team Paediatrician to consult regarding the most appropriate assessment plan.

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A CAT DAC seeking such authorization must be able to demonstrate the requirements outlined in Human Resources 2.2.4 and be prepared to conduct assessments of the entire range of catastrophic impairment criteria. The assessment of children should follow the intake and assessment processes outlined for general CAT DAC. Because of the unique nature of paediatric injuries, any cases involving paediatric claimants must be reported to the Accident Benefits Analysis Unit (ABAU) of the Financial Services Commission of Ontario (FSCO) for tracking purposes as soon as the referral is received.

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PART 2 DAC RESOURCES

2.1 Physical Resources

CAT DACs will operate in accessible facilities that comfortably provide the necessary interview, examination and testing areas. These facilities will be adequately equipped to deliver assessment processes described in this guide and have access to sufficient resources, including appropriate investigative and diagnostic technologies to conduct a comprehensive, individualized assessment.

In some circumstances, assessments may have to be conducted off-site in the claimant's home, institutional environment, or community. CAT DACs must be prepared to accommodate claimant needs without unreasonably delaying the assessment process. The location of the assessment should be clearly indicated in the final report.

As required with all DAC facilities, CAT DAC sites and facilities must be accessible to the mobility impaired (ie., wheelchair accessible).

2.2 Human Resources

The Human Resources complement for CAT DAC is structured into two co-ordinating roles -- Administrative Co-ordinator and Clinical Co-ordinator and two teams -- Core and On-Call. This structure is intended to ensure that CAT DACs conduct timely and comprehensive assessments with appropriately skilled and qualified health professionals in each of the catastrophic impairment criteria. Each member of the CAT DAC team should possess the following attributes and qualifications:

C A member in good standing and holds a current certificate of registration with the appropriate Ontario regulatory college.

C The necessary skills, knowledge, and ability to offer an opinion, considering the issue under consideration, the claimant's individual circumstances, age, impairment, and disability for each claimant assessed.

C A minimum of five years3 of current, continuing, and relevant practice. C Current means practice experience gained within the last seven years. C Continuing means the assessor is presently, or within the past five years, engaged in providing assessments either i) directly or ii) in supervising others or providing consultation to others in such provision.

3 Health professionals with less than the requisite five years' current, continuing, and relevant experience may participate in the assessment team if they have a minimum of three years' current, continuing, and relevant experience, and are under the supervision of a like discipline assessor who does meet the requirements.

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