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Comprehensive Rehabilitation Assessment in Multiple Sclerosis Social Work Perspective By Judy Soderberg,MSW, LISW

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Comprehensive Rehabilitation Assessment in Multiple Sclerosis Social Work Perspective By Judy Soderberg,MSW, LISW. Different types of Social Workers (In Minnesota – may differ in various states and countries.) All are licensed by State. A. Licensed Bachelor of Science in Social Work, BSW

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Comprehensive Rehabilitation Assessmentin Multiple SclerosisSocial Work PerspectiveBy Judy Soderberg,MSW, LISW
slide2
Different types of Social Workers

(In Minnesota – may differ in various states and countries.) All are licensed by State.

A. Licensed Bachelor of Science in Social Work, BSW

B. Licensed Social Worker, MSW

C. Licensed Clinical Social Worker, MSW

D. Licensed Ph.D. Social Worker

slide3
Social Workers work in a variety of settings and have various assessment and functions depending on setting and type of licensure.
      • Intake for various program, i.e., MSAC, Courage Center, Long

Term Care

B. Intake and follow for various county/state programs

slide4
C. Discharge planning

D. Intake/follow up for home care services

E. Information/referral services at local M.S. Societies

F. Attached to Comprehensive M.S. program

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Because of the variability of M.S., and the length of time people/families will deal with it, social workers from various settings and different licenses can be involved over time.
  • Tendency to be more involved with social workers as disease progresses particularly social workers who work in program of all types and in hospitals and home care. These are generally BS & MSW licensed social workers.
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Global assessments done by programs, hospitals and home care. Depending on information gathered in global assessment, other types of assessments may be requested.
slide7
Sample

of

Global Assessment

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Ability to express thoughts/needs/feelings:

___Expresses thoughts/feeling/needs without

difficulty

___Requires extra time or cuing

___Speech limited to single words

___Uses only gestures (eye blinking/eye or head movement/pointing)

___Unable to express thoughts/feelings/needs

(speech unintelligible or inappropriate)

___Unresponsive

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Patient’s living arrangement/care setting:

___Patient’s own home/residence

___Home of family member/friend

___Boarding home

___Assisted living facility/retirement center

___Hospital/Acute care facility

___Skilled nursing facility

___Long term care facility/Nursing Home

___Other (specify)__________________

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Patient’s Relationship Status:

_Single

_Married

_Divorced

_Domestic partner

_Widow/Widower

_Common law

_Separated

_Unknown

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If in a relationship, name of partner/spouse:

_________________________________

Age:_________________

Duration of relationship:_____________

Anniversary date:_____________

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Relationship of Primary Caregiver

__No primary caregiver available

__Spouse/significant other

__Natural child

__Step child

__Sibling

__Parent

__Friend/Neighbor

__Community/Church volunteer

__Paid Help

__Other (specify):_______________________

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Does the Caregiver Appear to Have any Limitations?

__Vision

__Hearing

__Speech

__Mobility/Endurance

__Emotionally unstable

__Alcohol/Substance abuse

__Conflict with patient

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__Concurrent treatment of own illness

__Inability to cope with potential loss

__Difficulty with own ADLs

__Lack of time

__Resistant to performing medical tasks

Family Members/Significant Others Not a Member of the Household:

________________________________

________________________________

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Social Support Systems (select one best description)

_Excellent social support system which

includes three or more willing family

members or friends

_Good social support system which

includes two or less willing family members

or friends

_Fair social support which includes one

willing family member or friend

_Poor social support; no willing family

members or friends; basically ALONE

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Patient’s Description of Illness/Current Health Status:___________________

_______________________________

__Patient unable/unwilling to discuss

__Knowledge/Understanding of Disease

Process

__Burden of Care

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Risk Factors:

_Alcohol abuse

_Financial resources inadequate to meet

basic needs (food/house/etc.)

_Financial resources inadequate to meet

health care needs

(supplies/equipment/medications)

_Food/Nutrition resources inadequate

_Home environment unsafe/inadequate for

home care

_Homicidal risk

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Risk Factors:

_Lives alone or without concerned relatives

_Multiple medications/complex schedule

_Physical limitations increase likelihood of

falls

_Plan of care/treatments complicated

_Substance use/abuse

_Visual impairment threatens safety/ability

to perform self-care

_Other (specify):__________________

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Abuse/Neglect (actual/potential risks):

_No signs of abuse/neglect

_Physical _Sexual

_History of abuse/neglect

_History of domestic violence

_Lacks adequate physical care

_Lacks emotional nurturing/support

_Lacks appropriate

stimulation/cognitive experiences

_Left alone inappropriately

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_Lacks necessary supervision

_Inadequate or delayed medical care

_Unsafe environment (I.e. guns/drug

use/history of violence in the

home/etc.)

_Bruising or other physical signs of

injury present

_Other (specify):_________________

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_Refer to child/adult protective services

_Other (specify):_________________

  • Mental Status:

_Alert – Oriented to

_Person _Place _Time

_Comatose – responds to:

_Verbal Stimuli _Tactile stimuli

_Painful stimuli

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_Forgetful

_Disoriented/Confused

_Lethargic

_Agitated

Other (specify):___________________

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Emotional Status: (mark all that apply)

_Angry _Euphoric

_Anxious _Fearful

_Apprehensive _Flat affect

_Avoidant _Helpless

_Clinging _Hostile

_Depressed _Impulsive

_Distraught _Irritable

_Elated _Labile

slide24
Emotional Status: (continued)

_Manic _Restless

_Sad _Suspicious

_Tearful _Withdrawn

slide25
Cognitive Functioning:

_No signs of impairment

_Impaired decision making

_Does not understand nature of health

condition on lifestyle

_Non-compliant with medical regimen

_Non-compliant with assistance

_Other (specify):_____________________

slide26
Functional limitations:

_Amputation

_Bowel/Bladder incontinence

_Contracture

_Hearing

_Paralysis

_Endurance

_Ambulation

_Speech

slide27
Functional limitations: (continued)

_Legally blind

_Dypsnea with minimal exertion

_Other (specify):________________

slide28
Current Sources of Stress in Addition to Current Illness:
  • _None reported

_Bills/Dept

_Career/Job change

_Child care (short term)

_Child care (long term)

_Death of a child (recent)

_Death of a parent (recent)

slide29
Current sources of Stress in Addition to Current Illness: (continued)

_Death of a spouse (recent)

_Employment status changed

_Family discord

_Financial loss/Inadequate income

_Job loss

_Legal issues unresolved

-Lifestyle change

slide30
Current sources of Stress in Addition to Current Illness: (continued)

_Marital discord

_Marriage within the last year

_Paperwork (insurance/legal,etc.)

overwhelming

_Separation/Divorce

_Other (specify):__________________

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Patient’s Income Level (per year):

_Less than $8,000

_$8,001-$14,000

_$14,001-$25,000

_$25,001-$40,000

_Greater than $40,000

_Patient refuses to provide information

Current source (s) of income:____________

___

slide32
Handling Finances:

_Independent: Manages financial affairs

without assistance

_Minimal Assistance: Needs prompting

(cuing/repetition/reminders to pay

bills/make deposits/cash checks or

manage financial accounts)

_Moderate Assistance: Needs supervision of all financial tasks

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Handling Finances: (continued)

_Total assistance: Unable to manage

her/his own financial affairs

_Financial matters handled by family/friend

  • Financial Concerns Expressed by Patients/Spouse:____________________

__________________________________

slide34
Current Community Resources Being Utilized (list):

_________________________________

_________________________________

_________________________________

slide35
Interventions/Plan of Care
  • _Assess social and emotion factors

_Counseling for long range planning and

decision-making

_Short term therapy

_Community resource planning/referral

_Other (specify):____________________

slide36
Community Resources Planning/Referrals:

_Child care

_Financial management/counseling

_Final arrangements

_Food/Nutrition support

_Home maintenance/repairs/handyman

services

_Homemaker services

slide37
Community Resources Planning/Referrals:

(continued)

_In-Home grooming services

_Legal assistance

_Mental health referral

_Protective services

_Relocation to different care setting

_Transportation

_Other (specify):

slide38
The global assessment gives information that could suggest a more targeted intervention. At this point a referral could be made to a clinical social worker to work with the person on their individual issues.
  • Referral from a team member if part of comprehensive MS Center
  • Self referral
slide39
VII. Individual Assessment – Clinical S.W.

A. Social Workers would assess social and emotional factors related to the impact of M.S. and the disability caused by it on the total life of the individual, their family, and the other social memberships, i.e., work, recreation interests, larger community.

slide40
VIII. Areas to be addressed in targeted assessment – In no special order.

A. Life style of individual – who they are as they define themselves

1. Family/home

2. Characteristics – coping style

3. Work

4. Recreation/interests

5. Other

slide41
B. Perception of how MS has affected their life style

C. What are the stresses in their life?

D. Specific areas of concern

1. Physical changes

2. Cognitive changes

3. Fatigue

4. Depression

5. Relationship Issues (partner,

parenting)

6. Work ?

7. Other

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E. Risk Factors: Alcohol abuse, social risk,finances, abuse.

F. Impact of MS on various parts of their life

G. Perception of things that need to be modified or changed

H. Grief/loss issues

I. What is issue that brought them to you.

J. Future focus

slide43
Development of plan based on individual perception of problem

-Many different options

-Individual counseling

-Couples counseling

-Family counseling

-Information or support group offered

by M.S. Society

slide44
-Community Resources

-OT/PT Speech referral

-Referral for specific services offered by physician, I.e., symptom management, depression management

-HUGA Program

-Volunteer opportunities

County/programs

slide45
Assessment by Social Worker and

patient to ascertain whether goals were met – decision point

-End point

_Additional referrals/services

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