Community Integration Program Claim Review Summary Form: Acquired Brain Injury (ABI) Please complete this form for injured workers with an eligible acquired brain injury for transfer into the Community Integration Program. Date sent to WorkSafe: Agent: ___________________________ Contact Name: ____________________ Date received by WorkSafe: Agent: ___________________________ Contact Name: ____________________ Return all completed forms and supporting documentation to: Health Operations (Community Integration Program) WorkSafe Victoria Level 21 222 Exhibition Street Melbourne VIC 3000 1 This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community Integration Program is subject to WorkSafe Victoria confirmation and endorsement Community Integration Program Claim Review Summary Form: ABI Note: 1. Information for this summary is to be retrieved from the file or ACCtion only. No additional contact is to be made with THP or worker at this stage. If information cannot be located, please indicate on form. 2. Please photocopy supporting material as you go. This will form the basis of the TAC file, together with ensuring the accuracy of all collected information. WorkSafe Victoria Agent: Claims Manager Name: Direct Contact Number: Claim Status: (select one) Worker’s Details WorkSafe Victoria Claim No: Worker name: Date of Birth: Current Age: Worker Address: Worker Phone number: Key emergency contact/s: (if relevant) Administrator/Guardian details (if relevant): Name Phone Relationship Domestic status: Name Age (if relevant) Living with worker Partner: Yes No Child : Yes No Parent (s): Yes No Siblings: Yes No 2 This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community Integration Program is subject to WorkSafe Victoria confirmation and endorsement Injury Details Date of Injury: Summary of accident: Generic Injury description: (e.g. moderate severe ABI) Detailed injury description: Acute Hospital details: Consultant’s name: Rehabilitation Hospital details: Consultant’s name Post injury surgery Date Surgery type / detail Outcome Name of Surgeon / Hospital Current issues Summary of pre-injury details Pre-injury medical status/conditions: Pre-injury medications/rationale: Pre-injury physical status: Pre-injury psych status: Pre-injury cognitive status: Pre-injury ADL independence: Pre injury domestic status: Pre-injury residential status: 3 This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community Integration Program is subject to WorkSafe Victoria confirmation and endorsement Current Status Residential status: Medical status: Conscious state / cognition: Communication: Physical/mobility: Psych / behaviour: Neuropsychology reports: Social: Education / Employment: Recreational involvement: Personal Activities of Daily Living (PADL)/Domestic Activities of Daily Living (DADL)/Communication Activities of Daily Living (CADL): Current Medications (Please copy and attach last 2 pharmacy invoices) Medication Name Prescribed Reason by (if known) Injury related or preexisting Dosage (If available) 4 This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community Integration Program is subject to WorkSafe Victoria confirmation and endorsement Current Service Provider Summary Name / Company Service Current approved hours / frequency Contact details Comment Commencement of date of service Current Medical / Paramedical / Rehabilitation Provider Summary (Please attach a copy of the current treatment notification form.) Name / Company Discipline Current approved hours / frequency Treatment/ Intervention goals Contact details Comment Commencement of date of service Current Vocational Status Pre injury / current occupation: Pre injury employer: Existing relationship with pre-injury employer: Existing RTW plan / suitable employment offer: Return to work status (e.g. current hours / duties / previous attempts to RTW: Level of education attained: Any post injury training / retraining: 5 This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community Integration Program is subject to WorkSafe Victoria confirmation and endorsement Current Equipment Summary Equipment Type/ Modification Details Date Cost (if relevant) Date of next review / Comment Wheelchair Recreational equipment Vehicle Home modification Other: Worker Objectives Home/Living: Vocation/Education: Recreation/Leisure: Community Independence: Common Law / Dispute resolution / Impairment / Income Common Law: Dispute resolution: Impairment: Income: 6 This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community Integration Program is subject to WorkSafe Victoria confirmation and endorsement Termination/ Reduction in services: Service type Date of termination /reduction Reasons for termination/reduction Disputation details (if applicable) Please attach payment sheet summary (from ACCtion) detailing all Medical and Like costs to date. Eligibility Assessment Agent Case Manager CM Review date MDT Case Conference date IMA review date IMA endorsement (Specify IMA) Injured worker Claim No: Date of injury Date of claim: Agent review outcome: The injured worker outlined above has been identified as meeting the WorkSafe Victoria/TAC definition of a catastrophic injury for the purposes of the Community Integration Program and may be eligible for transfer. Claim status: New claim (< 6 months from date of injury) Provide the following information: Severe ABI Indicator Actual Score Moderate ABI Indicator GCS GCS PTA PTA Actual Score 7 This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community Integration Program is subject to WorkSafe Victoria confirmation and endorsement Existing claim (> 6 months from date of injury): Attach completed claim summary tool Attach completed ABI Functional & Mobility Outcome Coding Specify information source (provide all relevant attachments i.e. Certificate of Capacity, TP reports). ABI Functional & Mobility Outcome Coding Please refer to the Functional Outcome Scale on Pages 10-13 before completing the table below. For further information, refer to the full ABI Functional Outcome Scale at the end of this form. Functional outcome scale 1. 2. 3. 4. 5. Minimal function Conscious but dependent Dependent in most tasks Independent but disabled Independent mild residual deficits Severity / skill Functional Description of function (brief) Outcome rating 1-5 (see above) 1. Conscious state 2. Cognition 3. Communication 4. Level of supervision 5. Personal care 6. Other Activities of Daily Living (ADL’s) 7. Mobility 8. Accommodation 8 This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community Integration Program is subject to WorkSafe Victoria confirmation and endorsement 9. Access / social/recreational 10. Vocational options 11. Concurrent issues 12. Psychological status / behaviour Total score The total score is derived by calculating the sum of each of the above functional outcome ratings Average The average functional outcome score is derived from dividing the sum of the total score by 12. Functional Outcome ABI Mobility code Please indicate client’s current level of mobility for each limb. Left LEG Right LEG Left ARM Right ARM No use Some use Full use -------------------------------End of form-----------------------------Please turn over for the CIP Supporting Documentation checklist and ABI Functional Outcome Scale reference. 9 This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community Integration Program is subject to WorkSafe Victoria confirmation and endorsement Community Integration Program Supporting Documentation Checklist: Acquired Brain Injury (ABI) Please tick each box once the relevant documentation has been attached. All boxes must be ticked before submitting your forms to WorkSafe Victoria. ABI CLAIM Community Integration Program Claim Review Summary Form (ABI) Last two pharmacy invoices attached (copies only) Current treatment notification form attached (copies only) Payment sheet summary from ACCtion printed and attached, detailing medical and like costs to date PLEASE NOTE: All sections of each form must be filled out in full. Blank sections or missing documents may result in your form being returned to you for clarification. This will cause delays in processing your claim review. 10 This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community Integration Program is subject to WorkSafe Victoria confirmation and endorsement ABI Functional Outcome Scale Severity 1 Skill Most severe General Functional level Minimal Function Conscious but dependent Dependent in most tasks Independent but disabled Independent with mild residual deficits 1. Vegetative state Generally alert – may be disorientated Alert and generally orientated Alert and orientated Alert and orientated Non responsive Severe cognitive deficits Follows commands, reduced capacity for decision making, problems with memory, new learning Assistance needed with planning, organisation, decision making – insight may be a problem Higher level/mild cognitive deficits in organisation, planning: fatigue can be a problem; generally insightful No discernible skill Some moderate prompting Problems with increased length or complexity of spoken or written language; frequently inappropriate in social context Problems with retention; may be verbose, tangential or disinhibited Mild, high level abstract language problems; may be inappropriate or face difficulty under pressure Total assist – 24 hour hands-on care Close supervision, cannot be left alone at night; significant attendant care Supervision, including care, in unstructured settings Some supervision with new, complex activities; may have low level care program Independent Fully dependent Dependent with personal care; always needs assistance/sup ervision/set up/ contact/mod assist Able to care for self partially, sometimes needs supervision/min assist with ADL Independent Independent Conscious State 2. Cognition 2 Communication 4. Level of supervision (safety), including care (funded or other) 5. Personal Care 4 Moderate (Includes memory, concentration, attention, orientation, problem solving, safety judgment, learning, organisation, insight…) 3. 3 5 Most mild 11 This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community Integration Program is subject to WorkSafe Victoria confirmation and endorsement Severity 1 Skill Most severe General Functional level Minimal Function Conscious but dependent Dependent in most tasks Independent but disabled Independent with mild residual deficits 6. Fully dependent Dependent, mod assist with DADL & CADL; cueing/assist with public transport Assistance of some level (either personal, domestic, community) assistance to access community – public transport, social pursuits due to safety issues Gets out and about to shops, uses public transport or drives, sometimes needs assistance with ADL’s (may be linked to ortho injuries) Generally independent including public transport or driving; minimal physical deficits Fully dependent Accompanying physical disability/ mobility, reduced coordination, may be wheelchair dependent; assist with transfers Walking or wheelchair independent; more physically able Independent may have ongoing physical complications from coexisting ortho. Injuries Independent Nursing home or equivalent level of accommodati on Supported residence (institution or home with family/carers) Either in community with support or supported residence Able to live independently with regular non-residential support Independent N/A Discontinued relationships, unable to return to previous social, recreational, vocational activities Suitable for supported recreational services, may need carer to accompany, difficulty sustaining independent relationships/net works Not possible to return to some previous activity (work, school, social) because of cognitive/ physical deficits Independent Other ADLs 7. Mobility 8. Accommodation 9. Access / social / recreation 2 3 4 Moderate 5 Most mild 12 This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community Integration Program is subject to WorkSafe Victoria confirmation and endorsement Severity Skill 1 Most severe 2 3 Moderate 4 5 Most mild General Functional level Minimal Function Conscious but dependent Dependent in most tasks Independent but disabled Independent with mild residual deficits 10. N/A Unlikely to return to work or any avocational activity Some possibility of RTW with extensive support; unlikely to compete in open job market; volunteer work a possibility Higher RTW potential –may be to different role or adjusted workload RTW or school potential with average performance; high proportion to pre-accident role, compete in open job market Medical issues i.e. high risk of pneumonia, epilepsy, contractures Medical issues i.e. epilepsy Medical issues i.e. epilepsy. Preexisting problems (drug & alcohol, social personality) may impact on outcome Pre-existing problems (drug & alcohol, social personality) may impact on outcome Pre-existing problems (drug & alcohol, social personality) may impact on outcome N/A Depression. Psych status may effect management; less ability to ‘act out’ but behaviour may be an issue. Moderate risk of demonstrating behavioural problems, agitation, aggression, impulsivity, withdrawn, adynamic; risk of self harm or harm to others; isolated. Depression High risk of demonstrating behavioural problems, agitation, aggression, impulsivity, withdrawn, adynamic; risk of self harm or harm to others; isolated. Depression Low risk of demonstrating behavioural problems, agitation, aggression, impulsivity, withdrawn, adynamic; risk of self harm or harm to others; isolated. Depression or Post Traumatic Stress disorder possible. Vocational options 11. Concurrent issues 12. Psychological status/ behaviour 13 This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community Integration Program is subject to WorkSafe Victoria confirmation and endorsement Further Information If you need advice or further information about the Community Integration Program or eligibility criteria, please contact the following representatives: Community Integration Program Manager WorkSafe Victoria 222 Exhibition Street Melbourne Vic 3000 Phone: 03 9940 4073 Team Manager Community Integration Program Transport Accident Commission (TAC) PO Box 2401 Geelong Vic 3220 DX 216063 Phone: 03 5225 6497 Toll free: 1800 651 953 14 This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community Integration Program is subject to WorkSafe Victoria confirmation and endorsement