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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


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  • 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


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C. Discharge planning various assessment and functions depending on setting and type of licensure.

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.


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Sample care. Depending on information gathered in global assessment, other types of assessments may be requested.

of

Global Assessment


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  • Ability to express thoughts/needs/feelings: care. Depending on information gathered in global assessment, other types of assessments may be requested.

    ___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: care. Depending on information gathered in global assessment, other types of assessments may be requested.

    ___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: care. Depending on information gathered in global assessment, other types of assessments may be requested.

    _Single

    _Married

    _Divorced

    _Domestic partner

    _Widow/Widower

    _Common law

    _Separated

    _Unknown


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  • If in a relationship, name of partner/spouse: care. Depending on information gathered in global assessment, other types of assessments may be requested.

    _________________________________

    Age:_________________

    Duration of relationship:_____________

    Anniversary date:_____________


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  • Relationship of Primary Caregiver care. Depending on information gathered in global assessment, other types of assessments may be requested.

    __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? care. Depending on information gathered in global assessment, other types of assessments may be requested.

    __Vision

    __Hearing

    __Speech

    __Mobility/Endurance

    __Emotionally unstable

    __Alcohol/Substance abuse

    __Conflict with patient


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__ care. Depending on information gathered in global assessment, other types of assessments may be requested.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) care. Depending on information gathered in global assessment, other types of assessments may be requested.

    _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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  • Risk Factors: Status:___________________

    _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: Status:___________________

    _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): Status:___________________

    _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 Status:___________________

_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 Status:___________________

_Other (specify):_________________

  • Mental Status:

    _Alert – Oriented to

    _Person _Place _Time

    _Comatose – responds to:

    _Verbal Stimuli _Tactile stimuli

    _Painful stimuli


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_Forgetful Status:___________________

_Disoriented/Confused

_Lethargic

_Agitated

Other (specify):___________________


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  • Emotional Status: (mark all that apply) Status:___________________

    _Angry _Euphoric

    _Anxious _Fearful

    _Apprehensive _Flat affect

    _Avoidant _Helpless

    _Clinging _Hostile

    _Depressed _Impulsive

    _Distraught _Irritable

    _Elated _Labile


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  • Cognitive Functioning: Status:___________________

    _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):_____________________


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  • Functional limitations: Status:___________________

    _Amputation

    _Bowel/Bladder incontinence

    _Contracture

    _Hearing

    _Paralysis

    _Endurance

    _Ambulation

    _Speech


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Functional limitations: (continued) Status:___________________

_Legally blind

_Dypsnea with minimal exertion

_Other (specify):________________


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  • Patient’s Income Level (per year): (continued)

    _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:____________

    ___


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  • Handling Finances: (continued)

    _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) (continued)

    _Total assistance: Unable to manage

    her/his own financial affairs

    _Financial matters handled by family/friend

  • Financial Concerns Expressed by Patients/Spouse:____________________

    __________________________________


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  • Interventions/Plan of Care (continued)

  • _Assess social and emotion factors

    _Counseling for long range planning and

    decision-making

    _Short term therapy

    _Community resource planning/referral

    _Other (specify):____________________


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  • Community Resources Planning/Referrals: (continued)

    _Child care

    _Financial management/counseling

    _Final arrangements

    _Food/Nutrition support

    _Home maintenance/repairs/handyman

    services

    _Homemaker services


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  • Community Resources Planning/Referrals: (continued)

    (continued)

    _In-Home grooming services

    _Legal assistance

    _Mental health referral

    _Protective services

    _Relocation to different care setting

    _Transportation

    _Other (specify):


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VII. Individual Assessment – Clinical S.W. 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.

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.


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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


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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


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-Community Resources problem

-OT/PT Speech referral

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

-HUGA Program

-Volunteer opportunities

County/programs


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