What is an anemia?

Low level of circulating oxygen in blood

What are the types of macrocytic anemias? (4)

B12 deficiency
Folate deficiency
Alcoholism
Thiamine deficiency
(BIG FAT RED CELLS)

What are the types of microcytic anemias? (4)

Thalassemia
Iron deficiency
Chronic disease
Sideroblastic

What does MCV show?

size of red blood cells

What is an aka for cooley's anemia?

thalassemia

What type of anemia is an inherited autosomal recessive anemia. Problem with the synthesis of hemoglobin. Microcytic, hypochromic anemia.

thalassemia

Where is thalassemia prevelent?

in mediterranean, south east asian, and middle eastern people.

What is the patient presentation of thalassemia?

poor growth, fatigue, gallstones, pathologic fractures, shortness of breath

What will physical exam reveal with thalassemia?

pallor, splenomegaly, jaundice, maxillary hyperplasia, dental malocclusion

What labs would you order if you suspect thalassemia?

CBC

What would a CBC show with thalassemia?

Normal or decreased Hgb, decreased MCV, and target cells (pale small cells with a dark center)
Fe studies are normal

What is patient management for thalassemia?

No treatment, transfusion if HgB falls too low. Diet recommendations of avoiding iron, drinking tea may decrease iron absorption

What is the most common medical disorder worldwide?

Iron deficiency anemia

What is this anemia? Rapid/slow blood loss, deficient intake or absorption, state of increase demand. Microcytic hypochromic anemia

Iron deficiency anemia

Iron is needed for the production and function of __________

hemoglobin

Risk factors for Iron deficiency anemia

Babies ingesting cow's milk prior to 12 months
vegan
frequent blood donor
chronic NSAID user
Blood loss (GI trauma, menses)
Decreased iron absorption (gastritis, surgery, celiac)
Increased demand (youth, pregnancy, breastfeeding)

Patient presentation with iron deficiency anemia (12)

-Pallor
-Increased HR
-Increased respirations
-cool extremities
-brittle nails/hair
-fatigue
-cheilitis
-PICA
-koilonychia
-melena
-exertional dyspnea
-Geographic tongue

Does iron show up on a CBC?

No

What labs would be ordered for iron deficient anemia?

CBC and iron studies

What lab results would come back with iron deficient anemia?

CBC
-Decreased HgB
-Decreased MCV
-Decreased Fe
-Decreased Transferrin
Saturation
-Increased TIBC
-Decreased ferritin

Management for iron deficiency anemia

-Iron supplementation
-Dietary recommendations of iron rich food (red meat, poultry, fish, dark green, lentils), vitamin c, decreased milk tea and coffee, increase fiber and water

Iron deficiency anemia happens because of what?

decrease in raw materials

What is the second most common anemia?

Anemia of chronic disease

What is this anemia? Chronic disease and inflammation inhibit erythropoiesis. Normochromic microcytic anemia

Anemia of chronic disease/ inflammation

What is anemia of chronic disease/inflammation associated with

autoimmune diseases, SLE, IBD, sarcoidosis, RA, Kidney disease, cancer, chronic infection

Patient presentation with anemia of chronic disease/inflammation

Mild/vague symptoms of anemia:
-Fatigue
-SOB
-lightheadedness
-palpitations
-decreased exercise tolerance

lab results with anemia of chronic disease/inflammation

-Increased ferratin level
-Decreased Hgb
-Decreased retic count

Can anemia of chronic disease/inflammation occur with other anemias?

yes

management of chronic disease/inflammation anemia?

Supplementary ferratin for inflammation but not chronic disease
Treat the cause
patient eduction (increase risk of mortality secondary to CV events)

What kind of marker is ferratin

inflammatory marker

types of chronic disease that causes anemia?

kidney disease
autoimmune
rheumatoid
(I listen to CDs in my KAR)

Clinical case management

provides individualized support and intervention to a client with serious illness which significantly limits their ability to access or engage in existing community services, ensuring that the person is able to remain in the community and not be re-hospitalized

Enhance client functioning through improving access to and use of resources
Attempt to influence bureaucratic systems and interdisciplinary services to work for the benefits of clients
More of the humanistic practice model

CCM Coordination of Services

Identifies gaps in service needs
Encourages effective use of services
Avoids duplication of services

CCM Social Supports

Quality of social supports is associated with:
-Sense of self-efficacy
-Personal empowerment
-Consider both structurally and functionally
-May be naturally occurring or orchestrated

Goals
-Enhance social supports
-Increase sense of connectedness and belonging
-Increase sense of safety

Person in Environment:

A practice-guiding principle in social work that highlights the importance of understanding an individual and individual behavior in light of the environmental contexts in which that person lives and acts.

Complete assessment must include social environment factor that influence the person's functioning
Housing
Safety
Employment
Medical care
Education
Support Systems

use of psychotropic medications in treatment

Accreditation

standardized program for evaluation healthcare organizations to ensure a specified level of quality as defined by a set of national standards.

ASO (Administrative Services Only)

An arrangement in which an employer hires a third party to deliver administrative services to the employer such as claims processing and billing; the employer bears the risk for claims.

advance Directive

A legal document designed to indicate a person's wishes regarding care in case of a terminal illness or during the dying process

adverse event

Unintended harm by an act of commission or omission rather than as a result of disease process

advocacy

taking action to influence others to address a health-related concern or to support a health-related belief

Algorithm

The chronological delineation of the steps in or activities of patient care as they relate to specific conditions and situations.

alternate level of care

a level of care that can safely be used in place of the current level. determined based on the acuity and complexity of the patient condition and the type of needed services and resources

Ambulatory Payment Classification (APC)

an encounter based classification system for outpatient reimbursement, including hospital-based clinics, emergency departments, observation and ambulatory surgery. Payment rates are based on categories of services that are similar in cost and resource utilization.

Ancillary Services

Supportive services other than routine hospital services provided by the facility, such as x-ray films and laboratory tests.

appeal

formal request to reconsider a decision to deny admission for healthcare services, reimbursement for services rendered or a patients request for extending the length of stay.

appropriateness of settings

Used to determine if the level of care needed is being delivered in the most appropriate and costeffective setting possible

Approved Charge
(INSURANCE)

The amount Medicare pays a physician based on the Medicare fee schedule. Physicians may bill the beneficiaries for an additional amount, subject to the limiting charge allowed.

Assessment

the process of collecting and interpreting relevant information about a client or research participant, gather through relevant sources in addition to direct contact with client, including health records, professional caregivers and family.

assistive devices

Special equipment that helps a person who is ill or disabled to perform ADLS; .

Assistive Technology

any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized that is used to increase, maintain, or improve functional capabilities of individuals with disabilities

autonomy

a form of personal liberty in which the patient holds the right and freedom to select and initiate his or her own treatment and course of action. Patient takes control of his health

Beneficence

obligation and duty to promote good to further and support a patient's legitimate interests and decisions and to actively prevent or remove harm.

beneficiary

an individual eligible for benefits under a particular plan. "members in an HMO plan" "enrollees in a PPO plan"

benefit package

The sum of services for which a health plan, government agency, or employer contracts to provide. In addition to basic physician and hospital services, some plans also cover prescriptions, dental, and vision care

Benefits

The amount payable by the insurance company to a claimant or beneficiary under the claimants specific coverage

burden of proof

the obligation to present evidence to support one's claim

Capitation

System of payment used by managed care plans in which physicians and hospitals are paid a fixed, per capita amount for each patient enrolled over a stated period regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the plan.

CARF Commission on Accreditation of Rehabilitation Facilities

A Private and non profit organization that establishes standards of quality for services to people with disabilities. offers voluntary accreditation for rehab facilities based on a set of nationally recognized standards

carve out

services that are excluded from a provider contract. Providers are not financially responsible for services carved out of their contract.

Caseload

The total number of patients followed by a case manager at any point in time

case management

A collaborative process that assesses, plans implements, coordinates, monitors, and evaluates the options and services required to meed an individual's health needs, using communication and available resources to promote quality and cost effective outcomes.

CMG- Case Mix Group

determines the base payment rate for inpatient rehabilitation facilities under the Medicare system.

Case Mix Index

The sum of the DRG relative weights of all patients/cases seen during a one-year period in an organization divided by the number of patients hospitalized and treated during the same year.

Case Rates
(INSURANCE)

Rate of reimbursement that packages pricing for a certain category of services. Typically combines facility and professional practitioner fees for care and services.

catastrophic case

Any medical condition or illness that has heightened medical, social, and financial consequences that responds positively to the control offered through a systematic effort of case management

claim

A request for payment of the benefits provided by an insurance contract.

clinical pathway/ Case management plan

A timeline of patient care activities and expected outcomes of care. Addresses the plan of care of each discipline involved in the care of a particular patient. It is usually developed prospectively by an interdisciplinary healthcare team in relation to a patient's diagnosis, health problem, or surgical procedure

Coding

a mechanism of identifying and defining patient care services/activities as primary and secondary diagnoses and procedures. Guided by ICD 10 codes.

Cognitive Rehabilitation

Therapy programs which aid persons in managing specific problems in
perception, memory, thinking and problem-solving. Skills are practices and strategies are taught to
help improve function and/or compensate for remaining deficits.

Co-insurance

a type of insurance in which the insured pays a share of the payment made against a claim.

community based programs

Support programs which are located in a community environment,
as opposed to an institutional setting.

Comorbidity

preexisting condition usually chronic that causes an increase in the length of stay by about one day in 75% of patients.

competence

the mental ability and capacity to make decisions, accomplish actions and preforms tasks that another person of similar background and trying would be reasonably expected to preform adequately.

concurrent review

review for medical necessity of tests and procedures ordered during an inpatient hospitalization

Confidential communication

a communication made within a certain protected relationship -such
as husband-wife, attorney-client, or priest-penitent -- and legally protected from forced disclosure

consensus

Agreement in opinion of experts; a method in developing case management plans.

Continued Stay Review

A type of review used to determine that each day of the hospital stay is necessary and that care is being rendered at the appropriate level. It takes place during a patient's hospitalization for care

CQI (continuous quality improvement)

a key component of total quality management that uses rigorous systematic organization-wide processes to achieve ongoing improvement in the quality of healthcare services and operations. Focuses on both outcomes and processes of care.

continuum of care

Matching an individual's ongoing needs with the appropriate level and type of medical, psychological, health, or social care or service within an organization or across multiple organizations.

Coordination

the process of organizing, securing, integrating, and modifying the resources necessary to accomplish the goals set forth in the case management plan.

Coordination of Benefits (COB)

an agreement that prevents double payment for services when a subscriber has coverage from two or more sources.

Copayment

A supplemental cost-sharing arrangement between the member and the insurer in
which the member pays a specific charge for a specified service. may be flat or variable
amounts per unit of service and may be for such things as physician office visits, prescriptions, or
hospital services. The payment is incurred at the time of service.

Credentialing

A review process to approve a provider who applies to participate in a health plan. Specific criteria are applied to evaluate participation in the plan. The review may include references, training, experience, demonstrated ability, licensure verification, and adequate malpractice insurance

Cultural Competency

a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals, that enables effective work in cross-cultural situations

Culture

the thoughts communications actions, customs, beliefs, values and institutions of racial, ethnic, religious or social groups.

Current Procedural Terminology (CPT)

A listing of descriptive terms and identifying codes for reporting medical services and procedures performed by health care providers and usually used for billing purposes.

Custodial Care

Care that is rendered to help an insured complete his/her activities of daily living.

Database

An organized comprehensive collection of patient care data. May be used for research or for quality improvement efforts.

Database Management System (DBMS)

A system for managing data that allows the user to store, retrieve, and analyze information.

Deductible

a specified amount of money that the insured must pay before an insurance company will pay a claim

Denial

when no authorization or certification is given by the insurance company for healthcare services because of inability to provide justification of medical necessity or appropriateness of treatment or length of stay.

developmental disability

Any mental and/or physical disability that has an onset before age 22
and may continue indefinitely. It can limit major life activities. Individuals with mental retardation,
cerebral palsy, autism, epilepsy (and other seizure disorders), sensory impairments, congenital
disabilities, traumatic brain injury, or conditions caused by disease (e.g., polio and muscular
dystrophy) may be considered developmentally disabled.

DRG (Diagnosis Related Group Classification)

A patient classification scheme that provides a means of relating the type of patient a hospital treats to the cost incurred by the hospital. Groups are based according to similar resource consumption and length of stay.

disability income insurance

A form of health insurance that provides periodic payments to replace income when the insured is unable to work as a result of illness, injury, or disease-not as a result of a work-related accident or condition

eligibility

the determination

Enrollee

An individual enrolled in a health benefit plan provided by a public or private healthcare insurance organization.

Ergonomics

The scientific discipline concerned with the understanding of interactions among humans and other elements of a system. optimizes human well-being and overall system performance.

Exclusive Provider Organization (EPO)

A managed care plan that provides benefits only if care is rendered by providers within a specific network.

fee schedule

A list of charges or established allowances for specific medical services and procedures

Fee-for-service (FFS)

an insurance payment system where providers are paid for each service, also called indemnity plan

Formulary

the prescription drugs covered by a specific health plan.

Functional Capacity Evaluation (FCE)

A systematic process of assessing an individual's physical capacities and function abilities. It matches human performance levels to the demands of a specific job, work activity, or occupation. provide objective information regarding functional work ability in the determination of occupational disability status.

Functional Job Analysis

defines the job requirements, both essential and non essential duties

Gatekeeper

a primary care provider who refers patients to other providers for services he or she cannot perform

Global Fee

A predetermined all-inclusive fee for a specific set of related services, treated as a single unit for billing or reimbursement purposes.

Group Model HMO

The HMO contracts with a group of physicians for a set fee per patient to provide many different health services in a central location. The group of physicians determines the compensation of each individual physician, often sharing profits

Habilitation

The process by which a person with developmental disabilities is assisted in acquiring and maintaining life skills 1) cope more effectively with personal and developmental demands 2) increase the level of physical, mental, vocational, and social ability through services.

Handicap

The functional disadvantage and limitation of potentials based on a physical or mental impairment or disability that substantially limits or prevents the fulfillment of one or more major life activities, otherwise considered normal for that individual based on age, sex, and social and cultural factors, such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, working, etc. Handicap is a classification of role reduction resulting from circumstances that place an impaired or disabled person at a disadvantage compared to other persons.

Health and Human Services Risk Management

The science of the identification, evaluation, and treatment of financial (and clinical) loss. A program that attempts to provide positive avoidance of negative results

health insurance

protection that provides payment of benefits for covered sickness or injury.

Health Maintenance Organization (HMO)

An organization that provides or arranges for coverage of designated health services for a fixed prepaid premium. Must consist of an organized system for providing healthcare in geographical area, an agreed-on set of basic and supplemental health maintenance and treatment services and a voluntarily enrolled group of people.

Healthcare Proxy

A legal document that directs the healthcare provider/agency in whom to contact for approval/consent of treatment decisions or options whenever the patient is no longer deemed competent to decide for self

Home Health Resource Group (HHRG)

groupings for prospective reimbursement under Medicare for home health agencies. Reimbursement rates correspond to the level of home healthcare provided.

Hospice

inpatient and outpatient care that is supportive, palliative and family-centered designed to assist a terminally ill individual be comfortable and maintain a satisfactory lifestyle through the end of life.

ICD-10-CM

International Classification of Diseases, 10th Revision, Clinical Modification. formulated to standardize diagnoses and is used for coding medical records in preparation for reimbursement.

impairement

a general term indication injury, deficiency or lessening of function. medically determined and relates to the loss or abnormality of psychological or anatomical structure or function.

Implementation

The process of executing specific case management activities and/or interventions that will lead to accomplishing the goals set forth in the case management plan.

indicator

a measure or metric that can be used to monitor and assess quality and outcomes of important aspects of care or services.

Individual Practice Association (IPA)

An HMO model that contracts with private practice physicians or a healthcare association to provide healthcare services for a negotiated fee. The physicians continue in their individual or group practice.

informed consent

consent given by the patient who is made aware of any procedure to be performed, its risks, expected outcomes, and alternatives

injury

Any wrong or damages done to another, may be done to his/her person, rights, reputation or property.

Inpatient Rehabilitation Facilities patient Assessment Instrument ( IRF-PAI)

An instrument that classifies patients into distinct groups based on clinical characteristics and expected resource needs. Determines the Case Mix group (CMG) classification.

Insurance Risk Management

A comprehensive program of activities to identify, evaluate, and take corrective action against risks; these risks may lead to patient or staff injury with resulting financial loss or legal liability. This program aims at minimizing losses

Integrated Delivery System (IDS)

A single organization or group of affiliated organizations that provides a wide spectrum of ambulatory and tertiary care and services. Care may also be provided across various settings of the healthcare continuum.

Intensity of Service

An acuity of illness criteria based on the evaluation/treatment plan, interventions, and anticipated outcomes.

intervention

planned strategies and activities that modify maladaptive behaviors or states of being and facilitate growth and change.

JCAHO

Joint Commission on Accreditation of Healthcare Organizations

Justice

maintaining what is right and fair and making decisions that are good for the patient

Length of stay (LOS)

Number of days a patient remains in a healthcare organization. The statistic is the number of calendar days from admission to discharge, including the day of admission but not the day of discharge. This statistic may have an impact on prospective reimbursement.

Level of Care

The intensity of effort required to diagnose, treat, preserve or maintain an individual's physical or emotional status

Levels of Service

Based on the patient's condition and the needed level of care, used to identify and verify that the patient is receiving care at the appropriate level

liability

legal responsibility to act appropriately or for actions that do not meet the standards of care inflicting harm on another person.

Life Care Plan

A dynamic document based on published standards of practice, comprehensive assessment, research and data analysis, which provides an organized concise plan for current and future needs with associated costs for individuals who have experienced catastrophic injury or have chronic healthcare needs

living will

a written statement detailing a person's desires regarding their medical treatment in circumstances in which they are no longer able to express informed consent, especially an advance directive.

Long Term Disability Income Insurance

Insurance issued to an employee, group, or individual to provide a reasonable replacement of a portion of an employee's earned income lost through a serious prolonged illness during the normal work career.

Malpractice

improper care or treatment by a healthcare professional. Wrongful conduct.

managed care

A system of healthcare delivery that aims to provide a generalized structure and focus when managing the use, access, cost, quality, and effectiveness of healthcare services.

Managed Competition

A state of healthcare delivery in which a large number of consumers choose among health plans that offer similar benefits. In theory, competition would be based on cost and quality and ideally would limit high prices and improve quality of care.

Maximum Medical Improvement (MMI)

When the injured worker has recovered from injuries to a level that a physician states further treatment will not substantively change the medical outcome. Not necessarily back to baseline.

Medicaid

A joint federal and state program that helps low-income individuals or families pay for the costs associated with long-term medical and custodial care, provided they qualify. Although largely funded by the federal government, it is run by the state where coverage may vary.

Medicaid Waiver

Waiver Programs, authorized under Section 1915(C) of the Social Security Act, provide states with greater flexibility to serve individuals with substantial long-term care needs at home or in the community rather than in an institution. The federal government "waives" certain Medicaid rules. This allows a state to select a portion of the population on Medicaid to receive specialized services not available to Medicaid recipients.

Medical Durable Power of Attorney (Health care proxy)

A legal document that names a surrogate decision-maker for a patient in the event that the patient becomes unable to make his or her own healthcare decisions.

Medically necessary

The supplies and services needed to diagnose and treat a medical condition in accordance with nationally recognized standards.

Medicare

a nationwide, federally administered health insurance program that covers the cost of hospitalization, medical care and some related services for eligible persons.

Medicare part A

The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care.

Medicare Part B

The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies.

Minimum Data Set (MDS)

The assessment tool used in skilled nursing facility settings
to place patients into Resource Utilization Groups (RUGs), which determines the facilities reimbursement rate

Monitoring

The ongoing process of gathering sufficient information from all relevant sources about the case management plan and its activities and/or services to enable the case manager to determine the plan's effectiveness

Negligence

failure to act as a reasonable person, Behavior is contrary to that of any ordinary person facing similar circumstances.

Network Model HMO

A type of insurance plan that contracts with groups of physicians and other providers in a network of care with organized referral patterns. Networks allow providers to practice outside the HMO.

Neuropsychological Evaluation

A test performed to acquire information regarding the cognitive, behavioral, motor, linguistic and executive functioning of an individual. This is done after a head injury to determine areas of deficits

Nomaleficence

Refraining from doing harm to others, emphasizing quality care outcomes.

outcome

The results and consequences of a healthcare process. It represent the cumulative effects of one or more processes on a client at a defined point in time. it may be the result of care received or not received. A result that achieved the intended goal

Outcome and Assessment Information Set (OASIS)

A prospective nursing assessment instrument completed by home health agencies at the time the patient is entered for home health services. Scoring determines the Home Health Resource Group (HHRG)

outcome indicators

Measures of quality and cost of care. Metrics used to examine and evaluate the results of the care delivered.

Outcomes Management

The use of information and knowledge gained from outcomes monitoring to achieve optimal patient outcomes through improved clinical decision making and service delivery.

Outcomes Measurement

The systematic, quantitative observation, at a point in time, of outcome indicators.

Outcomes Monitoring

the repeated measurement over time of outcome indicators in a manner that permits causal inferences about which patient characteristics, care processes, and resources produced the observed patient outcomes.

Patient Abandonment

Terminating the relationship with the patient without giving reasonable notice or providing a competent replacement, resulting in a lack of necessary medical care

payer

The party responsible for reimbursement of healthcare providers and agencies for services rendered, such as Center for Medicare and Medicaid Services or managed care organizations.

Peer Review

Review by healthcare practitioners of services ordered or furnished by other practitioners in the same professional field.

Peer Review Organization (PRO)

A Federal program established by Tax Equity and Fiscal Responsibility Act of 1982 that monitors the medical necessity and quality of services provided to Medicare and Medicaid Beneficiaries under the prospective payment system.

Per Diem

A daily reimbursement rate for all inpatient hospital services provided in one day to one
patient, regardless of the actual costs to the healthcare provider. The rate can vary by service
(medical, surgical, mental health, etc.) or can be uniform regardless of intensity of services.

Performance Improvement (PI)

The continuous study and adaptation of a healthcare organization's functions and processes to increase the likelihood of achieving desired outcomes

Physical Disability

A bodily defect that interferes with education, development, adjustment or rehabilitation; generally refers to crippling conditions and chronic health problems but usually does not include single sensory handicaps such as blindness or deafness.

Physician-Hospital Organization (PHO)

An organization of physicians and hospitals responsible for negotiating healthcare contracts with such third party payers as managed care organizations.

Planning

The process of determining specific objectives, goals, and actions designed to meet the client's needs as identified through the assessment process. It should be action oriented and time specific.

Point of Service (POS)

A type of health plan in which the covered person can elect to receive service from either a participating or a nonparticipating provider, with different benefit levels associated with each. Members usually pay substantially high premiums, deductibles and coinsurance.

Practice Guidelines (Guidelines)

Systematically developed statements on medical practices that assist a practitioner in making decisions about appropriate diagnostic and therapeutic healthcare services for specific medical conditions. Practice guidelines are usually developed by authoritative professional societies and organizations such as the American Medical Association.

Preadmission Certification

An element of utilization review that examines the need for proposed services before admission to an institution to determine the appropriateness of the setting, procedures, treatments, and length of stay.

Preauthorization/Precertification

The process of obtaining and documenting advanced approval from the health plan by the provider before delivering the medical services needed. This is required when services are of a nonemergent nature

Preferred Provider Organization (PPO)

An insurance program in which contracts are established with preferred providers of medical care. The benefit contract usually providers the covered individual significantly better benefits for services received from preferred providers, thus encouraging members to use the providers. covered persons are generally allowed benefits for nonparticipating provider services, usually on an indemnity basis with high copayments.

Primary Care

Th point at which the patient first seeks assistance from the medical care system. It also is the care of simpler and more common illnesses

primary care provider

A health care provider who assumes ongoing responsibility for the patient in both health maintenance and treatment. Usually responsible for orchestrating the medical care process either by caring for the patient or by referring the patient for specialized diagnosis and treatment.

Principal Diagnosis

The chief complaint or health condition that required the patient's admission to
the hospital for care.

Principal Pro

A procedure performed for definitive rather than diagnostic treatment. It is necessary for treating a certain condition. usually related to primary diagnosis.

Prospective Payment System (PPS)

A healthcare payment system used by the federal government since 1983 for reimbursing healthcare providers/agencies for medical care provided to Medicare and Medicaid participants. The payment is fixed and based on the operating costs of the client's diagnosis.

Prospective Review

Determine medical necessity prior to services

provider

person or entity that supplies medical or health services and bills for, or is paid for, the services in the normal course of business

Quality Assurance (QA)

the use of activities and programs to ensure the quality of patient care. these activities and programs are designed to monitor, prevent and correct quality deficiencies and noncompliance with the standards of care and practice.

Quality Improvement (QI)

An array of techniques and methods used to collect and analyze data gathered in the course of current healthcare practices in a defined care setting. Used to identify and resolve problems in the system and to improve the processes and outcomes of care.

Quality indicator

A predetermined measure for assessing quality; a metric.

Quality Management

A formal, planned, systematic, and organizationwide (or networkwide) approach to the monitoring, analysis, and improvement of organization performance. The purpose is to continually improve the extent to which providers conform to defined standards, the quality of patient care and the services provided, and the likelihood of achieving desired patient outcomes

Quality Monitoring

A process used to ensure that care is being delivered at or above acceptable quality standards and as identified by the organization or national guidelines.

Reasonable Accommodation

Mixing existing facilities used by and employee readily accessible and usable by individuals with disabilities . This may include restructuring, part-time or modified work schedules, acquisition or modification of equipment or devices and other similar accommodations for disabilities.

Rehabilitation

Restoration of form and function following an illness or injury. Restoration of an individuals capability to achieve the fullest life compatible with his abilities and disabilities. The development of a person the the fullest physical, psychological, social, vocational and educational potential consistent with his/her physiological or anatomical impairment and environmental limitations.

Relative Weight

An assigned weight that is intended to reflect the relative resource consumption associated with each DRG. The higher the relative weight, the greater the payment/reimbursement to the hospital.

Release

the relinquishment of a right, claim or privilege by a person in who it exits or to who it accrues, to the person against whom it may have been demanded or enforced.

Resource Utilization Groups (RUGs)

Classifies skilled nursing facility patients into 7 major hierarchies and 44 groups. Based on the Minimum Data Set the patient is classified int he the most appropriate group that provides the greatest reimbursement.

Respondeat Superior

a legal term meaning "let the master answer"; the employer assumes responsibility for the conduct of the employee and can also be held responsible for malpractice by the employee

retrospective review

The part of the utilization review process that concentrates on a review of clinical information following patient discharge

Risk Management

The science of the identification, evaluation and treatment of financial loss. A program that attempts to provide positive avoidance of negative results.

risk sharing

the process whereby a Health Maintenance organization and its contracted provider each accept partial responsibility for the financial risk and rewards of caring for the plan members assigned to that specific provider.

Root Cause Analysis

A process used by healthcare providers and administrators to identify the basic or causal factors that contribute to variation in performance and outcomes or underlie the occurrence of a sentinel event.

Self-Insurer

An employer who can meet the state legal and financial requirements to assume by him or herself all of its risk and pay for the losses, although the employer may contract with an insurance carrier or others to provide certain essential services.

severity of illness

An acuity of illness criteria that identifies the presence of significant/debilitating symptoms, deviations from the patient's normal values, or unstable/abnormal vital signs or laboratory findings

Short Term Disability Income Insurance

The provision to pay benefits to a covered disabled person/employee as long as he/she remains disable up to a specific period not exceeding two years.

skilled care

Patient care services that require delivery by a licensed professional such as a registered nurse or physical therapist, occupational therapist, speech pathologist, or social worker.

Social Security Disability Income

Federal benefit program sponsored by the Social Security Administration. Disability benefits received from a deceased or disabled parent depend upon money contributed to the Social Security program by the individual in solved and or the parent involved.

Staff Model HMO

a health maintenance organization that hires its own staff of health care providers and provide care exclusively for the health plan enrollees. Most Rigid model.

Standard (individual)

An authoritative statement by which a profession defines the responsibilities for which its practitioners are accountable.

Standard (Organization)

An authoritative statement that defines the performance expectations, structures, or processes that must be substantially in place in an organization to enhance the quality of care

Standards of Practice

statements of professional expectations for service delivery in order to assure systematic provision of recreation therapy services. Such statements are set by the organizations representing
the specific profession

statute

An act of a legislature declaring, commanding or prohibiting an action in contrast to unwritten common law.

subacute care facility

a health care facility that fills the gap between hospitalization and rehabilitation, by providing care to patients who are stable and don't need acute care, yet need more complex treatment than can be found in a nursing or rehabilitation facility

Subpoena

a process commanding a witness to appear and give testimony in court.

Supplemental Security Income (SSI)

A program established in 1972 and controlled by the Social Security Administration that provides federally funded cash assistance to qualifying elderly and disabled poor.

Supported Employment

Paid employment for persons with developmental disabilities who, without
long-term support, are unlikely to succeed in a regular job. Supported employment facilitates provide
competitive work in integrated work settings for individuals with the most severe disabilities (i.e.
psychiatric, mental retardation, learning disabilities, traumatic brain injury) for whom competitive
employment has not traditionally occurred, and who, because of the nature and severity of their
disability, need ongoing support services in order to perform their job. Supported employment
provides assistance such as job coaches, transportation, assistive technology, specialized job
training, and individually tailored supervision.

Third Party Administrator (TPA)

An organization separate from insuring organization that handles administrative functions such as utilization review and claims processing. Used to cost effective administer health benefits.

Ticket to Work Program

A voluntary program administered by the Social Security Administration for adults who receive benefits based on disability under the Social Security Disability Insurance (SSDI) program and/or the Supplemental Security Income (SSI) program. The purpose of the program is to provide expanded options for accessing employment services, vocational rehabilitation services or other support services needed to enter, maintain, and advance in employment

Tort

A civil wrong for which a private individual may recover money damages arising for a breach of duty created by law.

Tort Liability

The legal requirement that a person responsible, or at fault shall pay for the damages and injuries caused.

Utilization Management (UM)

Review of services to ensure they are medically necessary, provided in the most appropriate care setting and at or above quality standards.

utilization review

A mechanism used by some insurers and employers to evaluate healthcare on
the basis of appropriateness, necessity, and quality.

Utilization Review Accreditation Commission (URAC)

A not-for-profit organization that provides accreditation for utilization review services offered by freestanding agencies. It is also known as the American Accreditation Health Care Commission.

veracity

The act of telling the truth

Vocational Assessment

Identifies the individual's strengths, skills, interests, abilities and rehabilitation needs. Accomplished through on-site situational assessments at local businesses and in community settings.

Vocational Evaluation

The comprehensive assessment of vocation aptitudes and potential. Uses information about a herons's history and medical and psychological status as well as information from appropriate vocational testing, which may us paper and pencil instruments, work samples, simulated workstations or assessment in a real work environment.

Vocational Rehabilitation

Cost effective case management by a skilled professional who
understands the implications of the medical and vocational services necessary to facilitate an injured
worker's expedient return to suitable gainful employment with a minimal degree of disability.

Vocational Rehabilitation Counselor

A rehabilitation counselor, who specializes things such as guiding handicapped persons in the selection of a vocation or occupation.

Vocational Testing

The measurement of vocational interests, aptitudes, and ability using standardized, professionally accepted psychomotor procedures.

Work Adjustment

The use of real or simulated work activity under close supervision at a rehabilitation facility or other work setting to develop appropriate work behaviors, attitudes, or personal characteristics.

Work Adjustment Training

A program for persons who's disabilities limit them from obtaining competitive employment. Typically includes a system of goal directed services to improve problem areas such as attendance, work stamina, punctuality, dress, hygiene and interpersonal relationships with co-workers and supervisors.

work conditioning

Program focusing on returning a client to work, may:
-include restoring ability and capacity associated with work related tasks
Specifically designed to restore systemic functions such as Neuromusculoskeletal functions- joint integrity and mobility including strength power and endurance, ROM, Cardiovascular and pulmonary functions such as aerobic capacity/endurance and ventilation and respiration/gas exchange.

Work hardening

A highly structured, goal-oriented, and individualized intervention program that
provides clients with a transition between the acute injury stage and a safe, productive return to work.
Treatment is designed to maximize each individual's ability to return to work safely with less likelihood
of repeat injury. programs are multidisciplinary in nature and use real or simulated
work activities designed to restore physical, behavioral, and vocational functions. They address the
issues of productivity, safety, physical tolerances, and worker behaviors.

Work Modification

Altering the work environment to accommodate a person's physical or mental limitations by making changes in equipment, in the methods of completing tasks, or in job duties.

Work Rehabilitation

A structured program of graded physical conditioning/strengthening exercises
and functional tasks in conjunction with real or simulated job activities. Treatment is designed to
improve the individual's cardiopulmonary, neuromusculoskeletal (strength, endurance, movement,
flexibility, stability, and motor control) functions, biomechanical/human performance levels, and
psychosocial aspects as they relate to the demands of work. Work rehabilitation provides a transition
between acute care and return to work while addressing the issues of safety, physical tolerances,
work behaviors, and functional abilities

Workers Compensation

An insurance program that provides medical benefits and replacement of lost wages for person suffering from injury or illness that occurred in or was caused by the workplace. regulated primarily by the states but in certain occupations can be regulated by federal government.

Ombudsman

neutral source of assistance to address the healthcare service concerns of local citizens. Public employees that provide confidential independent assistance in addressing health svcs, problems and conflicts when other options fail. Established in 1972.

Education for All Handicapped Children Act of 1975

act that established the right of all children to a free and appropriate education, regardless of handicapping condition. development of proper evaluation and classification procedures and Individualized education programs based on the evaluation.

Kurtosis model

method of describing the shape of grouped data. Not part of statistical analysis.

Abraham Maslow

Humanistic psychologist known for his "Hierarchy of Needs" and the concept of "self-actualization" (1943)

Nationwide Referral Resources for Senior Services

1. 211-24 hour telephone information referral through United way,
2. Eldercare locater
3. Snap for seniors
4. Case management Resource guide.

Planning - SMART Goals

Specific
Measurable
Attainable
Relevant
Time-specific

ADLs (DEATH)

Dressing,
Eating,
Ambulating,
Toileting,
Hygiene

IADLs (instrumental activities of daily living)

more complex activities. Laundry, shopping for groceries, using a telephone, cooking, shopping, housekeeping, finances, taking medications, preparing meals, fixing things around the house, lawn care,

Transtheoretical Model of Change

1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance
1979 James Prochaska

Lewin's Change Model

-Unfreezing: create the motivation to change
-Changing: new information, models, and procedures
-Refreezing: support and reinforce the change

EMTALA (Emergency Medical Treatment and Active Labor Act)

regulates all emergency care of patients to ensure there is no delay because of inability to pay

Milliman Care Guidelines (MCG)

guideline for EBP in clinical setting, develops clinical tools used by hospital to put together EBP in industry.

Anterior Knee Pain

Patellar Subluxation or Dislocation

Anterior Knee Pain

Tibial Apophysitis (Osgood-Schlatter lesion)

Anterior Knee Pain

Jumper's Knee (Patellar Tendonitis)

Anterior Knee Pain

Patellofemoral Pain Syndrome (chondromalacia patellae)

Medial Knee Pain

Medial Collateral Ligament Sprain

Medial Knee Pain

Medial Meniscus Tear

Medial Knee Pain

Pes Anserine Bursitis

Medial Knee Pain

Medial Plica Syndrome

Lateral Knee Pain

Lateral Collateral Ligament Sprain

Lateral Knee Pain

Lateral Meniscus Tear

Lateral Knee Pain

Iliotibial Band Tendonitis

Posterior Knee Pain

Popliteal Cyst (Baker's Cyst)

Posterior Knee Pain

Posterior Cruciate Ligament Injury

Knee Trauma with Hyperextended Knee

ACL Injury

Knee Trauma Hit from Outside

MCL, ACL or Meniscus

Knee Trauma with Weight on Knee, Twisted It

Meniscus

Knee Trauma with Bent Knee, Fell On or Hit Front of Knee

PCL

Knee Trauma with Pop at Time of Injury

ACL, Meniscus, or Fracture

Knee Trauma with Immediate Joint Swelling

ACL or Fracture

Knee Trauma with Delayed Swelling

Meniscus or Other Joint Irritation

Knee Trauma where Knee Painfully Locks in 1 Position

Meniscus or ACL

Knee Trauma where Knee is Held in 20-30 Degree Flexion to Avoid Pain

Fluid in the Joint

Knee Pain in the Front of Knee After Repetitive Activity Worse with Jumping

Patellar Tendonitis or Osgood-Schlatter Disease

Knee Pain on the Outside of Knee After Repetitive Activity Worse with Downhill Walking

Popliteal Tendinitis or ITB Syndrome

Knee Pain on the Inside of Knee After Repetitive Activity Worse with Breastroke Kick, Bicycling, or Skiing

MCL Sprain; Possible Pes Anserinus Strain

Knee Complaint of Stiffness with Past History of Trauma or Surgery

Postmeniscectomy likely; Trauma; Adhesions from Poor Rehabilitation

Knee Complaint of Stiffness in a patient of Increased Weight or Age

Osteoarthritis

Knee Complaint with a Sense of Weakness or Instability with Past Injury of Painful Swelling Resolving with Increasing Stability

ACL Insufficiency due to past tear

Knee Complaint with a Sense of Weakness or Instability with Past/Current History of Low Back Pain

Neurologic Weakness

Knee Complaint with Other Problems that Seemed to Occur at or Slightly Before the Beginning of the Knee Pain with Other Joints that Hurt

Check for Arthritides

Hip Pain with Fall- Able to Bear Weight & Walk

Hip Pointer or Contusion

Blow to the Thigh, hit in front, difficulty flexing the knee

Quadriceps Contusion

Blow to the Thigh; hit in the back; hurts to bend forward

Hamstring Contusion

Sharp Pain in Thigh or Groin While Performing a Sport or Recreational Activity; Hurts to Flex or Fully Straighten Knee

Hamstring Pull

Sharp Pain in Thigh or Groin While Performing a Sport or Recreational Activity; Hurts to Lift the Leg

Iliopsoas or Adductor Strain

Sharp Pain in Thigh or Groin While Performing a Sport or Recreational Activity; Hurts to Extend the Knee

Quadriceps Strain

Hip Complaint with Previous Respiratory Infection

Septic or Aseptic Synovitis

Hip Complaint with Menstrual Irregularities

Possible Gynecologic Referral

Hip Complaint with Pain Worse at Night; Recent Weight Loss; Previous History of Cancer

Metastasis or Primary Tumor

Hip Complaint with Pain in Both Hips AND Hand or Finger Pain

Rheumatoid Arthritis

Hip Complaint with a Noticed Change in Hat Size

Paget's Disease

Hip Complaint with Previous Trauma or Previous Disease of the Hip

Osteoarthritis

Hip Complaint with Pain Radiating from the Back to the Groin

Renal Pathology

Hip Complaint with Pain in the Groin with Bearing Down or Lifting

Inguinal Hernia

Hip Complaint RED FLAG

Unable to Move Hip or Bear Any Weight

Meralgia Paresthetica

Hip Complaint; compression of the Lateral Femoral Cutaneous Nerve

Pattern of Numbness Discrete, Following a Dermatome Corroborating Neurologic Findings to Confirm Location

IVD, Stenosis, Fracture, Tumor, or Vascular Malformation

Pattern of Numbness Fits a Discrete Area for a Specific Peripheral Nerve with Corroborating Motor Findings of Specific Nerve

trauma, overuse, or metabolic causes

Pattern of Numbness Diffuse; Distal & Bilateral with Little or No Motor Findings

metabolic disorder

Symptoms of Peripheral Neuropathy

Gradual Onset of Numbness & Tingling (Paresthesia) in Feet & Hands, Which May Spread Upward into Legs and Arms

Symptoms of Peripheral Neuropathy

Burning pain or sharp, jabbing or electric-like pain

Symptoms of Peripheral Neuropathy

Extreme sensitivity to tough (dysesthesia)

Symptoms of Peripheral Neuropathy

lack of coordination (ataxia)

Symptoms of Peripheral Neuropathy

Muscle weakness or paralysis

Symptoms of Peripheral Neuropathy

muscle atrophy

Symptoms of Peripheral Neuropathy

diminished deep tendon reflexes

Symptoms of Peripheral Neuropathy

bowel or bladder problems (autonomic nerves affected)

Low Back Pain with Injury of Falling on Buttocks

compression or coccygeal fracture

Low Back Pain with Injury with Sudden Hyperflexion

compression or chance fracture

Low Back Pain with Injury that Appeared While Lifting or with Sudden Twisting

Disc Lesion or Muscle Strain

Low Back Pain with Injury with Sudden Extension Injury

Facet Injury

Low Back Pain with Pain that Continues into the Buttocks or Leg Below the Knee

nerve root pain due to disc, stenosis, or tumor

Low Back Pain with Pain that Extends into the Buttocks or to the Knee

Lumbar Facet, SI Joint

Low Back Pain with Difficulty with Urination or Defecation with Numbness Around the Groin or Genital Area

Cauda Equina Syndrome

Low Back Pain with Leg Pain When You Defecate, Cough or Sneeze

Space Occupying Lesion: Tumor or Disc Lesion

Low Back Pain with Frequent Urination and/or Difficulty Stopping or Starting

Prostate Cancer

Low Back Pain with Abdominal Pain Associated with Menstrual Cycle

Dysmenorrhea, Endometriosis, PID

Low Back Pain with Abdominal Pain that Radiates Around to the Groin

Kidney (infection or stone)

Low Back Pain with Abdominal Pain and Associated Leg Weakness

Abdominal Aneurysm

Low Back Pain with Marked Weight Loss with a Past History of Cancer, Night Pain, Pain Unrelieved with Rest

Cancer

Low Back Pain Associated with Weakness in the Legs with Activity that is Relieved Quickly with Rest

VASCULAR Claudication

Low Back Pain Associated with Weakness in the Legs with Activity that is Better When Flexed and/or Relieved After 15-20 Minutes of Rest

NEUROGENIC Claudication

Cervical Strain

History of Trauma; Pain Radiating into Head, Shoulders, & Arms

Postural Strain

History of Forward Head; Pain Radiating into Neck, Head, Shoulder & Arms

Cervical Joint Facet Sprain/Ligamentous

History of Trauma; Pain/Stiffness of Neck; Protective mm Spasm; Pain May Radiate to Occiput and Into Shoulders

Osteoarthritis/Degenerative Joint Disease/Degenerative Disc Disease

neck pain & stiffness; decrease in ROM; pain may refer to interscapular, shoulders, & occipital regions; radiculopathy may be present with IVF encroachment

Myelopathy (Cord Compression)

presentation may differ with type/degree of compression; bilateral symptoms of clumsiness of hands, difficulty walking, possible urinary dysfunction; possible shooting pains into arms

Cervical Complaint RED FLAGS

severe trauma/direct head trauma (with loss of consciousness); nuchal rigidity; bladder dysfunction with onset of neck pain; associated dysphasia; associated cranial nerve or CNS symptoms

Rheumatoid Arthritis

neck pain; neurologic manifestation (easily fatigued, difficulty walking with sensory loss)

Cervical Disc Herniation

pain in neck & shoulder radiating down the arm in the distribution of the involved nerve root; parasthesia; numbness; sensory & reflex deficits

Disc Lesion with Radiculopathy

PPW low back pain & leg pain generally below the knee, often of sudden onset from a bending and/or twisting maneuver *past history of several bouts of LBP resolved

Facet Syndrome

PPW localized LBP with some hip/buttock or leg pain, generally above the knee; sudden, misjudged movement, arising from flexed position

Canal Stenosis

50s or older, back & leg pain, pain unilateral or bilateral, diffuse, leg complaints with walking (claudication), relief after resting 15 - 20 minutes or maintaining flexed posture

Spondylolisthesis

Asymptomatic or LBP worse with extension

Sacroiliac Sprain & Subluxation

PPW pain over 1 SI joint after straightening up from a stooped position; pain may radiate down 1 leg; sprain- sharp & stabbing

Piriformis Syndrome

PPW buttock & posterior leg pain, non-traumatic onset

Cervical spine injury with head forced forward

Sprain/strain of posterior neck muscles/ligaments, fracture of vertebral body, facet dislocation, disc lesion

Cervical spine injury with head forced back

Sprain/strain of anterior neck muscles/ligaments, facet compression, hangman's or teardrop fracture at C2-C3

Cervical spine injury with head turned and flexed

Facet subluxation or dislocation, sprain/strain

Cervical injury with head stretched to the side

Brachial plexus stretch lesion, facet fracture, nerve root compression on side of head flexion

Cervical injury with head turned and extended

Facet compression, articular pillar fracture, sprain/strain

Cervical injury hit top of head

Jefferson's fracture

Cervical injury with pain radiating into arm (s) with isolated weakness or numbness

Nerve root involvement

Cervical injury with pain radiating into the arm(s) & associated numness/tingling that resolves over a few minutes

Burner or stinger (if involved with Lateral flexion injury)

Cervical injury with pain radiating into the arm(s) & associated difficulty with walking or urinary dysfunction

Myelopathy RED FLAG

Cervical injury with pain radiating into the arms(s) with more numbness and tingling in a diffuse or ill-defined pattern

Referred pain from facet

Cervical injury unable to move head in a specific direction- woke up with it

Acute "pseudotorticollis"

Cervical injury unable to move head in a specific direction- associated with fever, worse with flexion

Possible meningitis

Cervical injury unable to move head in a specific direction- gradual onset

Osteoarthritis

Cervical injury unable to move head in a specific direction- after head or neck trauma

Fracture or dislocation

Cervical injury with chronic pain or stiffness with local pain with specific movement

Subluxation

Cervical injury with chronic pain or stiffness with work involving forward head posture or Lateral flexion while on the phone

Postural syndrome

Broken down by sex and age

Male median (IQR): 26 (21, 32)
Female median (IQR): 29 (23, 37)

Substance misuse

Substance misusers [except tobacco]
Have a greater chance of persistent low grade psychotic symptoms
Have a greater chance of later Sz
Earlier start & heavier use increases risk more
Become ill 2-5years younger
Then have worse outcomes in every respect

10-20 00,000 per annum
Good to stop cannabis, helps psychotic symptoms

Suicide

Almost 1% per year initially, eventually 4-6%; cohort and case-control studies more like 10%
More likely if substance misuse; recent suicidal ideation; feel hopeless, trapped & alienated; stop meds
Maybe half serious DSH is probably before 1st treatment, so 4-6% prob. underestimates

DSH - SEVERE SELF HARM

Number of homicides by people with non-affective psychosis

England - from NCI 2014
Mean 32 per annum
57% patients, 79% actively psychotic
About 12 per 100,000 per annum, a bit over 10x general population as for the rest of Europe

FIRST EPISODE TREATMENT
FE Rx: Medication

APS - low dose if not too agitated
For agitation
benzodiazepines
For motor side effects (stiff)
Reduce dose or anticholinergics, propranolol
For depression between episodes
antidepressants

FIRST EPISODE TREATMENT
Antipsychotic drugs

All reversibly block D2 receptors
Dose inversely related to affinity for receptor
>60% occupancy of D2 in associative striatum has an antipsychotic effect
>75% occupancy of other D2 causes motor SE & hyperprolactinaemia

Clozapine

Licensed for Treatment Resistant Schizophrenia (TRS)
TRS if two antipsychotics
fail or
can't be tolerated at full dose
About 20% of early Sz, maybe 30% eventually eligible
Substantial symptom reduction in 30-50% of TRS
Prob. about 80% under 3 y, 30% after then
Prob. reduced impulsivity:
violence, self harm, drug use
Enables people to engage in rehab activity, improves quality of life
"Dirty drug": many SE
Often include sedation, hunger, hypersalivation, diabetes
Rare SE: agranulocytosis
Hence rigorous blood monitoring regime
meds can't be dispensed without clear FBC
No depot, needs specialist service

Milieu

Contain behaviour and emotion safely
Ongoing warmth, empathy, positive regard
Sufficient support
Monitor risk and mental state
Suitable activity as recover

Insight and Adherence

40% non-adherent at any time
?60% over 1 week at some point
Increases relapse odds x5
Predicted by:
Don't see a medication benefit
Don't think will relapse
Don't like medication and internal LoC
Poor insight, poor relationship with prescriber

Epidemiology

· Cohort of first episode (first psychosis) sufferers
o Predominantly young men
o Gender ratio becomes more equal after the peak in the 20-25 range
o Females out number males in onset >40
· The symptoms patients present with when their younger - negative, disorganisation, hostility, excitement symptoms - are less common in older patients
· The level of psychosis (hallucinations + delusions) is just as much (but less frequent?)
· Depression + psychosis is common across the board
· But other symptoms show a big age differential - this has a big impact on prognosis
· Typical incidence: 10-20 per 100,000 per annum
· Class differential: more common in lower social class groups
· Services are thus geared towards working-class young men/people

risk factors for schizophrenia

· There are a range of risk factors for schizophrenia (genetic + environmental), accumulating more risk factors = higher total risk of getting schizophrenia
o But certain risk factors multiply each other, e.g. gene for not handling dopamine well in frontal lobe + smoking cannabis
o Individual risk factors may seem to have a small affect and may not affect all people in all environmental conditions but combining it with a particular environment + other risks = big impac

Substance misuse

· ANY Substance misusers
o Have a greater chance of persistent low grade psychotic symptoms
§ Apart from when they are smoking
o Have a greater chance of later developing Sz if they are persistent in substance misuse
o Earlier start + heavier use increases risk more
o People using cannabis/alcohol Become ill 2-5 younger
o Once you have Sz, substance misuse (apart from tobacco) then leads worse outcomes in every respect
· Cannabis
o Dose-response curve for cannabis suggesting a causal relationship
§ If you start cannabis earlier+ use it more heavily then your more likely to go on to develop persistent psychotic symptoms and then psychosis
· People smoking cannabis + having genetic vulnerability to Sz = develop psychotic symptoms + later Sz
§ People who don't have genetic vulnerability may never develop it at all no matter how much cannabis they smoke

The premorbid course of people who are going to develop Sz /Aetiology

· Early development in people who later develop psychosis
o IS already reduced in function so if you walk, stand later, potty train later, talk later = more likely to develop psychosis + Sz
o Attentipon impaired
o No friends at primary
o Clumsy
o School essays worse
This shows how long lasting the processes are that make you vulnerable

· Early Prodrome :

o Conduct disorder -.g. being criminal , the more symptoms of conduct disorder you have especially oppositional defiant conduct disorder = increases
o May develop more anxiety + depression symptoms
o People develop what looks like negative symptoms
§ Apathetic, less engaged with things, don't do well in school, stop achieving things, don't get a job or a girlfriend
So low grade non-specific symptoms build up and the persons social functioning in response reduces further and furthre

Late prodrome - soft quasi-psychotic symptoms develop

o Increasingly suspicious
o Overvalued ideas
o Hear odd bits of hallucinations and pseudo hallucination

And then full psychosis develops
· But people may stop this process and exit from it at any point
o They can exit + continue with the negative symptoms + anxiety depression + not functioning well
o Or can exit and these symptoms may resolve + their function improves
At the prodrome stage:
· 1/3 get better
· 1/3 carry on into the graph course
· 1/3 develop psychosis
· IQ is lower in people who develop psychosis - this isn't universal, just group average observation
o IQ drops near to the first episode of psychosis

Treatment

· The earlier the treatment the better
· Symptoms that aren't treated for a while respond less well when treatment is eventually started
· Relationship between treating psychotic symptoms vs duration of untreated psychosis
o chances of responding to treatment are high if symptoms are treated almost immediately
o Some people get 100% resolution of psychotic symptoms + excitement symptoms if they get almost immediate treatment
o If you wait 12 weeks, only about 60% of psychotic or other symptoms will resolve
o Curve flattens by 108 weeks (<40% resolution) and relationship between waiting longer and getting a worse response is GONE so doesn't matter anymore to get them treated quickly

Suicide

Sz patients: almost 1% per year in Sz patients in their 1st year of treatment, eventually 4-6% of people diagnosed with Sz commit suicide
o Cohort and case-control more like 10%
· Maybe half of incidence of serious deliberate self harm (jumping off something high but service, survive hanging themselves or overdose or going infront of something moving fast) is probably before 1st treatment
o Thus around 4% of people not yet treated may kill themselves
o So not treating them patients is very risky
· Suicide More likely if
o Substance misuse
o Recent suicidal ideation
o Feel hopeless
o Trapped and alienated
o Stop meds - because this is associated with being psychotic, low and hopeless which is the situation in which people kill themselves
§ Around 2% of people who stop their Sz meds kill themselves
So for these, treatment should be started quickly

Homicides

· Homicides by not-yet diagnosed Schizophrenic people is another reason why treatment should be started early
· A group of people with Sz overall are about 10x more likely than the general population in the UK to commit homicide ( brazilians nowadays or americans 1980s)

First Episode Treatment
Medication

· APS - low dose if not too agitated
· For agitation
o High dose of a more sedative APs to slow them down a bit
o Benzodiazepine - add in this to calm people and sedate to reduce
· For motor side effects of APs e.g. stiffness (less common with 2nd gen)
o Reduce dose
o or anticholinergics - reduce parkinsonian side effects
o Or propranolol - reduce side effects like akathisia
· For depression between episodes
o Antidepressants - ADs also likely to have a good prophylatic effect against recurrent episodes of depression
o Depression during a psychotic episode - NO evidence that ADs do anything for this, the depression here Is probably due to the psychosis - e.g. thinking you're persecuted, or feeling low because this is your first episode of psychosis.
§ As psychotic symptoms resolve mood should too

First Episode Treatment
Antipsychotics

· All reversibly block D2 receptors
o Dose inversely related to affinity for receptor
· >60% occupancy of D2 in associative striatum has an antipsychotic effect
o Prevents big fluctuations in DA
· >75% occupancy of other D2 causes motor SE & hyperprolactinaemia
o Motor side effects - parkinsonian and others

Psychosis after first presentation + treatment

· Xontrary to belief that it takes a few weeks for APs to work, Reduction in psychosis + positive symptoms + efficacy (bloackage) is actually fastest early on and then tails off
· It takes a couple of weeks for effects to be so obvious that they're definitely noticiable + evreyrone is going to response
· People who don't respond much in first five weeks are much less likely to get a response later on
· By 9 months - a quarter of people don't have any symptoms at all

Negative symptoms

· Hardly reduce
· Amount of negative symptoms after 18months on treatment is pretty much determined by amount of negative symptoms they have upon presentation

Changing Antipsychotic

· For people who don't respond to 1st APs they don't respond well to a different second AP either generally (only 4% make improvement on AP2)
· So now move them onto CLOZAPINE

Clozapine

· Licensed for Treatment Resistant Schizophrenia (TRS)
· TRS if two antipsychotics
o fail or
o can't be tolerated at full dose
· this is About 20% of people with early Sz, maybe 30% of Sz patients eventually eligible because of deterioration
· Substantial symptom reduction in 30-50% of TRS
· Prob. about 80% reduction if given in under 3 y after diagnosis/presentation, 30% after then
· Clozapine Prob. reduced impulsivity:
o violence, self harm, drug use
· this Enables people to engage in rehab activity, improves quality of life
· "Dirty drug": many SE - so must be used continuously . High doses can be very toxic
· Side effects:
o Often include sedation, hunger, hypersalivation, diabetes, high cholesterolaemia
· Rare SE: agranulocytosis -
· Hence rigorous blood monitoring regime to ensure minimum efficacious dose is being given and to check serum levels
· next weeks dose of clozapine can't be dispensed before a clear FBC for the week. This is 2 weekly for a year and then monthly after
· No depot (no long acting injection), needs specialist service to make drug work and monitor

APs to prevent relapse

· Must continue APs because they don't cure the underlying processes causing Sz, they just stop the psychotic processes that make the symptoms
Need Milieu - not just APs
•An environment that can Contain behaviour and emotion safely
-Ongoing warmth, empathy, positive regard even if you do something bad like violence etc
-Sufficient support
•Must be able to Monitor risk and mental state
•Must have Suitable activity as recover so they don't get bored, fed up, stressed, and negative symptoms get worse if you don't have anything to do
These conditions are critical for successful recovery in your social environment

Family Intervention

· Helping families to deal with their guilt and anger reduces the emotional distress and burden on the family because they feel they can cope with the problems
· Reduces the risk of relapse for the patient by hal

Cognitive Behavioural Therapy for Psychosis

· Talk about what delusions are
· How to test them
· How to interpret what people are doing e.g. to deal with reference delusions
· How are they going to deal with the voices

Social Support

•Supported Accommodation - people may have lost jobs, housing
•Families
•Groups - to avoid institutionalisation (constant routine where daily activities established = worsens negative symptoms loads and leads to institutionalisation)
-Meaningful activity - training and then work hopefully
-Support
-For general or specific sub-groups
•Vocational interventions, employment
•Education & training

Cognitive remediation

· The cognitive impairments before developing Sz, follow similar course of cognitive loss like the rest of the peopulation after diagnosis/treatment
o They have a gentle loss of overall IQ or fluid executive function sort of performance (ability to juggle different things at the same time)
· Activities which improve executive function -
· Cognitive remediation improves Sz executive performance, skill and social functioning
· Help reduce decline in fluid IQ for Sz patients

Risk of relapse

· If you havent already relapsed, the risk is about 80% by five years
· So about 20% of people get away without relapsing for the first 5 years
· Half of relapses because people stop taking their meds
· Other half because people no longer responding to meds

Insight and Adherence

Insight = not thinking your ill, or knowing your ill but thinking you won't relapse, or thinking your medication doesn't work
The less insight you have the higher the chance of being re-admitted (lowest insight = 2x as much chance of re-admission as high insight)
•40% non-adherent at any time
•?60% will stop for over 1 week at some point
•Increases relapse odds x5
•Predicted by:
-Don't see a medication benefit
-Don't think will relapse
-Don't like medication and internal LoC
-Poor insight, poor relationship with prescribe

Compliance

Definition: taking less than three quarters of prescribed drug for a week
Symptom Outcomes
· Never to relapse
· Remitted
· Symptomatic, not remitted
· Treatment resistent, don't respond
After 5 years there's more treatment resistant people
By 20 yeaers , there are less treatment resistant people, and majority of people will have remitted
· But part of the reason people here do worse is non-adherence still
Outcome variable, 80% relapse, most have deteriorating course that may improve after 15-20 years
Life expectancy late 50s/early 60s

The responsibility of the case manager includes:

Assessing the individual's total situation and addressing the needs and problems found in that assessment

Once the client has been linked to the services he or she needs, the case worker must:

Continue monitoring the client's progress and advocating for his or her needs

Ethical practices in the social services are in place because:

They prevent the exploitation of the individuals seeking human services

Guarding an individual's confidentiality means that the human services provider can/should:

Discuss the case only with colleagues for their professional opinion with a patient's verbal consent

According to the NASW Case Management Standards Manual, family is very narrowly defined as parents, children and grandparents.

False

According to the NASW Case Management Standards, when a conflict between primacy of the client's interest and the goals or policies of organizations or delivery systems occurs, the case manager should use mechanisms such as peer review, ethics committees, or external consultation, or should advocate for internal change, to resolve the dilemma.

True

Beyond assessment and planning, what are the 2 other steps of case management?

Monitoring and Linking

Strangers are:

People whose ways of acting are different and who are not members of our in-group

Some people have difficulty coping with the changes brought on by developmental transitions in life. These life stages may include:

Going to high school

We apply the ecological model of human services in order to:

Understand the individual within the overall context

Because of internalized verbal and nonverbal scripts within a culture that may be different from your own, you should:

Check your perceptions with the person in a nonjudgmental way

It is the ethical responsibility of human services workers to become familiar with the culture of the client so that:

Cultural differences do not become obstacles to good communication

Cultural competence in human services workers to improve cross-cultural communication is achieved by:

Being more adaptable to, and flexible in, choosing how to respond to situations

Mental mechanisms that can block clear communication and create conflict include:

Ethnocentrism, prejudice and stereotypes

Cultures, subcultures, race and ethnic groups are examples of:

Sociological divisions among people

A person from a collectivist culture would tend to:

Communicate in a more ambiguous way to avoid hurting or imposing on others

In our efforts to improve communication with someone who is different from us, we:
(this is a tricky question, read/consider carefully!)

Habitually categorize them

Approaching the school superintendent together with the social service professionals in the children's case management unit to advocate for an improvement in the school's academic supports offered would be referred to as a(n) ______ intervention.

Macro-level

The service plan the human services worker designs for the client should be two-pronged and should include___________ interventions.

Personal and environmental

A person's individual characteristics interact with external circumstances to affect his or her outcome. Some of these individual characteristics (micro level context) include:

Motivation

In order to develop a balanced understanding of the client, the case manager must:

See what the client brings to the situation, such as personality characteristics that affect the larger context of that person's life

The context level immediately surrounding the client such as family, church group, close friends, etc. would be considered

The meso level

Aspects of the personal context that a person grew up in and is now functioning in (meso level context) include:

Social class

When we project our own assumptions about persons from a different culture, we:

Are attempting to reduce our own anxiety or uncertainty about them

Aspects of the social context that a person grew up in and is now functioning in (macro level context) include:

Prejudice and discrimination

The case manager's ability to address issues on the three context levels is referred to as:

The generalist approach

Seeking exceptions to cultural stereotypes helps us to:

Gain a more accurate understanding of the individuals we are serving

When the client owns the problem, ______.

The human services worker must decide how much help to give

The client may remind the case manager of someone from the past that causes the case manager to identify with the client. This is an example of:

Countertransference

It is the role of the human services worker to support patients' efforts to take charge of their lives and make decisions. This support can take the form of:

Having Realistic goals for the client and encouraging progress towards the goals

A 17-year-old single mother of a severely disabled child has been disowned by her family and seeks help sorting out her situation:

The client owns the problem, but the case manager needs to take the reins in finding a solution in consultation with the client

A social service provider's ethical responsibilities to the individual in his or her care include:

Meeting the client's own needs and best interest

Knowing who owns the problem is important because:

It allows us to understand who is ultimately responsible for resolving the problem

When a client comes to you with a problem, ______.

Listen, provide resources and help the client arrive at a solution

As case managers, we need to erect useful boundaries between ourselves and the client. This means:

Understanding the differences between our situation and the client's situation despite possible similarities

A worker establishes a warm atmosphere by:

Being friendly, nonjudgmental and receptive

The case manager may remind the client of someone from the past whom he or she dislikes. This is an example of

Negative transference

Suppose the client needs evening appointments, but the case manager works only during the day. This means:

Both the client and the case manager own the problem, and it is an opportunity to negotiate a solution

The person who owns the problem is:

The person whose needs are not being met

Deinstitutionalization directly led to which change in the planning and implementation of treatment plans

Family involvement in the process

When assessing for strengths in all clients, particularly children, it is highly useful to present them with:

Choice

A Hobby:

s a legitimate area for strength-based assessment

Lack of resources, culture, language, and mental illness all constitute potential ______________ to achieving goals.

Barriers

Intellectual Disability is most likely to affect which part of the service plan?

Follow through

Following the planning meeting, the case manager should meet with which individual first?

The client

A client phones you. He states that he is undergoing a crisis. You...

Respond immediately

Therapeutically speaking, a crisis:

Can be the catalyst for growth

Which of the following is an inappropriately written goal statement?

"Natasha, with the assistance of her educational counselor Vickie, will decide on a realistic training program."

A target date can:

Be shortened or extended

The chief importance of the discharge summary is:

As a roadmap to assist future providers in understanding the case

Treatment goals should be included in the discharge summary:

Regardless of whether or not they were achieved