PUBLICATIONS - LIFE CARE PLANNING
Clinical Interview and History
The clinical interview and history is a critical component
of the evaluation and data collection process. The value
of the interview goes well beyond the basic information collected
through the questions presented in the interview format.
Preparing for the Interview Process
The format of the clinical interview and history includes
multiple sections. A generic set of questions makes up the
core information that crosses all disability groups. The
forms for the patient's present treatment, supplies, equipment,
and family history accompany this set of questions. It is
preferable to have at least one family member present during
the clinical interview and history process. The presence
of a family member gives the rehabilitation professional
an opportunity to gain insight into family dynamics, an additional
perspective on the disability from someone close to the patient,
and valuable insight into psycho-social aspects of disability
that cannot be obtained from just interviewing the patient.
With a brain injury patient, it is critical to have a family
member present who knew the patient pre-morbidly. If a family
member is not available, include a close friend who knew
the patient prior to the onset of the disability. It is only
in this fashion that one can gain effective insights into
pre- versus post-injury levels of function in higher-level
executive function; psychological, emotional, and behavioral
function; and motoric function areas.
Review the Records and Pre-Evaluation
Material
Prior to conducting the interview, review and summarize
the medical, health-related, professional, rehabilitation,
educational, and employment records the patient has assembled.
In addition, consider sending a pre-evaluation homework assignment
to the patient and/or family consisting of the present treatment
section, the supply section, and the equipment section of
the interview sheets. This option enables him or her to assemble
all the necessary information in advance of the interview.
Many people will gather the information and properly complete
the forms before the interview. Although it may still be
necessary to review these with the patient and family to
develop further information and ensure you have a full understanding
of the situation, this method saves a great deal of time.
Even when forms have not been fully completed, the information
will already be organized, giving everyone a head start on
accomplishing the job.
Members of the Patient's Treatment
Team
In the present treatment section, make sure patients assemble
all their current physicians' names, specialties, phone numbers,
addresses, date of last visit, frequency of visits, and purpose
of last visit. If they know the cost of an office visit,
they should note this as well. Gather the same information
for counselors, therapists, and anyone they might be seeing
for alternative medical intervention such as acupuncture.
Prescription Medications
With respect to medications, it is important to obtain
the basic information such as dosage, prescribed frequency
of administration, purpose for which the medication is being
given, and the name of the physician prescribing the medication.
During the interview, be sure to ask how the medication is
being taken, regardless of whether they have noted the frequency
of administration or not. Also ask what they understand the
purpose of the prescription to be. Patients and family members
can sometimes have rather unusual understandings regarding
diagnosis, basic physiology, and medication usage. Part of
the clinical interview process is to ferret out patient perceptions
and misconceptions.
Pre-Interview Telephone Conference
Next, conduct a pre-evaluation telephone interview with
the patient and/or a family member closely involved with
patient care to complete salient portions of the clinical
interview and history. This telephone interview is particularly
important when you are traveling out of the office to see
the patient. If you are taking any materials, such as testing
supplies, it can be extremely helpful to gather insights
in advance of the interview. This will also shorten the evaluation
process, reducing it to a tolerable duration for patients
with more severely disabling conditions. In addition, it
allows the clinician/rehabilitation professional to enter
the evaluation process well informed and comfortable with
the process.
The Orientation
Prior to engaging in the interview process, your first
step is to initiate your role as an educator with the patient
and family. Begin by introducing yourself, your background,
and the purpose of your involvement in the case. If you are
acting as a case manager, explain exactly what that role
entails. If your intent is to complete a life care plan,
define what that is and how one goes about building such
a plan. Explain your role and the patient's role in the process
because such a plan cannot be built without the patient's
participation. If forensics is involved, it is particularly
important to define your role and explain that you are not
their advocate. Advocacy is the role of their attorney. You
are there to educate all parties involved about disability
and its impact on the life of the patient and the family.
You are there to explain how disability impacts independent
living, the ability of the patient to perform activities
of daily living, and the ability to function in an educational
setting or at work. You can discuss the impact of age and
disability combining over time to create phase changes in
the life care plan. It is your responsibility to use practice
guidelines, research literature, reference texts, and your
own knowledge base to build a foundation for the life care
plan. It is important for the patient and family to appreciate
your role, background, knowledge base, and ability since
their active participation is necessary to help you complete
your outlined responsibilities. The more confidence they
have in you, the more help they will provide in supporting
the job you have to complete.
The Ground Rules
You should begin the interview process by discussing a
few basic ground rules with the patient and family members.
Keep in mind that this portion of the interview is generic
in nature and applies to all patients, regardless of disability.
Therefore, use discretion in applying some of the comments,
according to the nature of the disability. As one case in
point, this reading includes a few concrete examples of applications
to brain injury versus non-cognitive impairments.
Family Participation
Generally, you should conduct the clinical interview in
the presence of both the patient and family, with few exceptions.
At times it is reasonable to ask selective questions of a
patient without a family member present, but it is rarely
necessary to ask questions of the family with the patient
removed. Simply conduct the orientation in an open, straightforward
manner. Give the patient a sense of control, and treat each
individual like an adult. Let patients know that if they
feel tense, stressed, or agitated, they can request a break.
At the same time, the interview is about them, and it is
preferable to have them present.
As you ask each question, request that the patient try
to answer the question first; only then should family members
provide their perceptions or a corrected response. At no
time should they answer for the patient or talk over the
patient. If the family does so, resist the urge to immediately
correct them because part of the objective of the evaluation
is to observe family dynamics. Observing these interactions,
even after hearing specific instructions regarding this process,
can be extremely insightful. After a family member has continued
to interrupt a patient two or three times, reiterate the
fact that you need to hear a complete response from the patient
first. If the pattern later begins to repeat itself, make
note of the behavior and intervene once again.
Identifying, tracking, and carefully noting such patterns
in family dynamics and interactions can help in the design
of the family counseling and individual behavioral or counseling
programs built into the life care plan. In this fashion,
the plans become very workable in the real world instead
of just a shell for show.
Pediatric Patients
Even in the case of the pediatric patient, try to conduct
much of the interview with the parents while the child remains
in the room. This approach allows you to observe the child
for two or more hours before beginning to work with the child.
Again, note family dynamics and interactions. You also may
have the chance to observe tube feeding, child behavior patterns,
seizure activity, or even the child in free play. Note the
child's independent ability to move or thrust his/her extremities,
to crawl, to roll, or to walk. In addition, the interview
provides an extended period of time for the child to get
used to the life care planner's voice. Take care to keep
your voice calm, low-key, and non-threatening throughout
the interview. Remember that part of your goal is to have
the child view you as non-threatening and your visits painless,
compared to the many prior doctor visits that child may have
experienced.
Length of the Interview
It is important to plan sufficient time to get through
the interview process. Depending on the complexity of the
disability, you typically will need three to four hours if
you are utilizing the format provided in this course, coupled
with one of the disability-specific forms.
For many of the questions asked relative to the common
disabilities you will evaluate, you will only be looking
for a basic answer from the patient. With some patients,
(the brain injured, the psychiatric/psychological patient,
and others), you will find yourself looking beyond the basic
response for insight.
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Demographic Information
The individual with a brain injury who cannot provide a
social security number, telephone number, or address can
be providing you a significant detail. At the same time,
do not jump to conclusions. Check whether the patient and
family moved recently, or even in the last six months. If
they moved post-trauma, the patient's memory lapse may be
an indication of difficulty in learning and retaining new
information. If it is a pre-morbid address, the patient's
inability to respond accurately may reflect much more significant
damage. On the other hand, if the problem is psychiatric
in nature, the issues, although significant, may reflect
much different insights.
In each instance, no matter how long it may take, it is
important to try and establish the patient's response first.
The patient's memory of what is accurate, perception of what
is going on, and understanding of what is wrong all represent
important insights into the dynamics of the disability.
As you move through the questions, it is important to establish
where the individual was born and where he or she received
elementary and secondary education. This information can
help provide some important insights into educational development,
even within state educational systems.
Nature of the Injury
In asking how an individual was injured, it is important
to steer away from issues of liability. You are not requesting
a reconstruction of the accident. The issues within this
section relate merely to the mechanics of the injury.
Did the individual lose consciousness? If so, for how long?
Does he or she recall the accident? Is there any loss of
memory for events prior to the accident, (retrograde amnesia)?
If there was a loss of consciousness, did the patient awaken
at the scene? Does he or she recall emergency workers at
the scene or being treated at the scene? Does the patient
recall transport to the hospital or treatment in the ER?
When were family members first notified of the accident?
How long after the accident did they arrive at the hospital?
How long was it before they saw the patient? Did the patient
recognize family members? What were family members told by
the doctor?
Rehabilitation Programs Since Onset
The next step is to move the patient through the initial
hospitalization into all rehabilitation programming since
the onset of the disability to the present. It is best to
do this with your notes on the medical records by your side.
What does the patient remember of the acute care experience?
What does he/she recall of the inpatient rehabilitation program?
What therapies did he/she receive? Was the rehabilitation
program a positive experience? What levels of function and
independence did he/she achieve? On discharge, where did
the patient go? What level of support care did he/she require?
Who provided that care? Did the patient receive any outpatient
rehabilitation programming? Can he/she recall what therapies
were recommended and on what schedule? It is important to
track this information through to the current schedule the
patient is receiving, including his or her attitude about
therapy.
Prior Medical History
A complete review of the patient's prior medical history
is important. Life care planning deals with the whole patient,
not just the current disability. At times, depending on the
basis for establishing the plan, we may have to distinguish
between the preexisting medical history and the current disability,
but we always deal with the whole person.
Did the patient have any history of accidents or injuries
resulting in any hospitalizations, medical care or disability?
Was there a prior history of chronic medical or health care
conditions for which the patient was being treated such as
asthma, heart disease, high blood pressure, pulmonary disorders,
and the like? Had the patient ever been treated for any psychiatric
or psychological conditions or been prescribed psychotropic
medications? Establish whether the patient had any surgeries
or had ever been hospitalized.
Chief Complaints and Current Disability
Approach chief complaints or current disability in three
ways. First, ask the patient to describe his or her understanding
of the diagnosis and to list the primary problems or complaints,
as they currently exist. Do this without regard to what has
occurred historically; base it on what is occurring now.
It may help to request that the patient disregard the fact
that you have read his or her medical records and to imagine
he/she is introducing the problems to you for the first time.
Again, ask the family not to interrupt, and to note that
they will be asked the same question after the patient responds.
Tell the patient that when he or she is done, family members
will be given the opportunity to give their perception. Perceptions
may differ, and it may not be easy for the patient to listen
to what others have to say. Although patient can leave if
they wish, it is preferable that they not do so. Nevertheless,
if they would like a break at any point, all they have to
do is request one.
Second, after the patient and each family member has had
the opportunity to provide insight into the disability from
their perspective, turn to disability-specific questions.
These questions are specifically designed to address areas
of difficulty commonly expressed by those with a certain
type of injury.
Third, it is important to document the disability from
the patient and family perspective with great specificity.
This detail should be included not only in your notes, but
also be translated from your notes to your report.
Such documentation by the plaintiff's life care planner
or case manager is critical in a forensic setting. When you
are given the task of considering the needs of a patient
from the defense perspective, without the opportunity to
personally evaluate the patients, these reports then become
your eyes and ears, and you rely on such notes for critical
insights.
Psychosocial Issues
Patient and family psychosocial issues are the next area
of input. Although the rehabilitation professional may be
tempted to provide only his or her own insights, this is
not the purpose of this section. Ask the patient what insight
he/she has into the psychological response to the onset of
disability, then ask how the patient sees the disability
having impacted his or her family. Subsequently, ask the
family to give input. If the rehabilitation professional
has comments to make from his or her own observations thus
far in the interview, it is appropriate to make them as long
as they are carefully distinguished from those of the patient
or family members.
Physical Limitations
The questions in this section are straightforward as long
as the professional remembers the following: Unlike some
chronic low back patients with workers compensation claims,
some patients with catastrophic disabilities will answer
based on what they hope to be able to do in the future, rather
than what they are currently able to do.
It is important to obtain a realistic understanding of
the patient's current physical limitations and abilities.
This is another reason for trying to have at least one family
member present during the interview. Explore each item carefully
and, depending on how far post-injury the patient may be,
consider having a follow-up interview. For example, if you
are interviewing a spinal cord patient 8 to 10 months post-injury,
then a follow-up interview at 14 to 18 months post-injury
(and even longer post-injury, if possible) is certainly in
order.
Environmental Influences/Activities
of Daily Living (ADLs)/Social Activities/Personal Habits
Although all the questions are fairly straightforward,
any question in the clinical interview can represent subtleties
beyond the basics. Reviewing social activities with a patient
can reveal social isolation, withdrawal, and signs of depression
or anxiety disorder. In reviewing personal habits, it is
appropriate to determine if anyone in the home is smoking
or has an alcohol or drug problem. Smoking, even if the patient
is a non-smoker, has significant implications for skin care
in spinal cord injury, due to exposure to second-hand smoke.
The interviewer must focus on more than concrete facts. Instead,
develop a critical thinking framework and look beyond the
obvious in your interview technique.
Employment History
Typically, an employment history is something you should
ask the patient to do as a homework assignment prior to the
interview. Once accomplished, you should review it with the
patient during the interview. This history is an excellent
source of pre-morbid data on patient levels of function.
Work provides insight into a patient's level of educational
development, ability to work with people, task orientation,
ability to focus and concentrate, physical capacities, mental
capacities, and a wide range of other data. Jobs can be broken
down through worker trait groups into very specific requirements,
providing immense detail about an individual's pre-morbid
levels of ability and function. This history is much more
than just a resume.
Observations
This is the interviewer's opportunity to comment directly
on what he/she has observed about the patient's mental status
in the evaluation. Orientation addresses whether the patient
was alert and oriented to person, place and time (oriented
times three).
Was the patient's stream of thought clear and rational
or confused, bizarre, disjointed, or tangential? Was the
patient able to clearly communicate thoughts when asked direct
questions?
Was the patient's overall approach to the evaluation positive,
negative, flat, or indifferent? Did the patient show an overall
positive attitude and seem to have insight into his or her
physical and psychological problems?
Comment on the patient's overall appearance. Was the patient
well cared for? Did the patient appear overtly disabled?
Did the patient demonstrate a lot of chronic pain behaviors?
Was the patient demonstrating a lot of chronic disability
behaviors? Any relevant comments the interviewer wishes to
make would be pertinent in this section.
Tests Administered
Unless you are conducting psychological or developmental
tests, this section is irrelevant and should be skipped.
General Comments
The comment section is available for general comments or notes
the interviewer wishes to make.
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