A Team Approach to Care for We have nothing to disclose Children - PowerPoint PPT Presentation

3/9/2018 A Team Approach to Care for We have nothing to disclose Children with Cerebral Palsy Christina Buysse, MD Helen Phung, PT Supervisor Patty Walsh, OT Chief Therapist California Children’s Services CCS Medical Therapy Program • CCS was established in 1927 by the State of California to provide medical case coordination for children ages birth to 21 • Eligibility • Medical • Residential • Consists of CCS Administration and CCS Medical Therapy Program 1

3/9/2018 CCS Pilot Project CCS Administration • Senate Bill (SB) 586: Department of Health Care • Statewide program administered by each Services (DHCS) to establish the Whole-Child county Model (WCM) program • It arranges, directs and pays for medical care, • Incorporates California Children’s Services (CCS) equipment & rehabilitation for children and into Medi-Cal managed care plan (MCP) young adults under 21, historically for eligible • Health Plan San Mateo (HPSM) has operated conditions only the first pilot program since 2014 • Clients must be medically and financially • HPSM contracts with CCS San Mateo eligible CCS Pilot Project Medical Therapy Program (MTP) • Improves care coordination for CCS children • Established in 1945 for both CCS and non-CCS conditions • Maintains CCS program standards including • Funded 50% by the state and 50% by the counties services provided by CCS paneled providers • • Comprehensive treatment focuses on the Physical & Occupational Therapy whole-child, addressing the full range of • needs, not just the CCS health condition Eligibility • Minimal impact on services at the Medical • No financial eligibility • Residential Therapy Program to date • Medical 2

3/9/2018 Children served: birth to 21 years Location where services are provided • Medical Therapy • 2 Unit (MTU) • Housed in public schools • 2 MTUs • 1 Satellite Eligible diagnoses Referral process • Neurologic • Anyone can refer Cerebral palsy, Spina bifida, Spinal cord injuries, • Parents, teachers, nurses, Traumatic brain injuries, At risk for cerebral palsy under age 3 social workers, doctors • Requirements • Orthopedic • CCS application Arthrogryposis, Osteogenesis imperfecta, Arthritis, • Current medical report Amputations • Doctor’s prescription for • Neuromuscular OT & PT evaluation Muscular dystrophy, Spinal muscular atrophy, Myopathy • http://www.dhcs.ca.gov/services/ccs/Pages/ apply.aspx 3

3/9/2018 Eligible diagnosis – at risk for CP • CCS applicants under three years of age shall be eligible when two or more of the following neurological Meet Ava findings are present: • Exaggerations of or persistence of primitive reflexes beyond the normal age (corrected for prematurity) • Increased Deep Tendon Reflexes (DTR) that are 3+ or greater • Abnormal posturing as characterized by the arms, legs, head, or trunk turned or twisted into an abnormal position • Hypotonicity, with normal or increased DTRs in infants below one year of age. • Asymmetry of motor findings of trunk or extremities Ava Enrollment in CCS-MTP • First seen in CCS- • Born at 36 MTU at 11 months weeks gestation • Small for old • Not yet sitting gestational age • Hospitalized for independently • Using right hand 2 weeks in the more than left NICU working • Hypertonia on feeding • Accepted into the issues program with diagnosis of “At- risk for CP” 4

3/9/2018 Medical Course Developmental Progress Over Time • She continued to • Feeding was a challenge; grow very slowly syringe fed. Oral motor • Head MRI therapy was initiated. • Nice pincer grasp normal • She began to sit • Facial differences unsupported, then crawl, were noted then stand independently • Initial round of • Still not walking genetic testing independently • Using all of her limbs was normal symmetrically • Second tier of • No braces or equipment genetic testing • Limited language revealed a diagnosis Determination of Medical Eligibility – Determination of Medical Eligibility – Age 3 Age 3 • Taking one or two steps; • No qualifying diagnosis of nice movement patterns CP that suggest she is • Services will be capable of walking transitioned to the school without assistance district and private • Normal muscle tone and therapists for ongoing OT reflexes and PT services when she • Symmetrical use of arms turns 3 and legs 5

3/9/2018 How are therapy services determined? Strength OT and PT Evaluation • Assessments commonly used • Range of motion • Gross Motor Skills • Strength • Activities of Daily Living • Neurologic status • Oral Motor Skills • Balance and • Perception Equilibrium • Mobility • Postural alignment • Gait • Hip surveillance • Fine Motor Skills Activities of daily living Fine motor skills 6

3/9/2018 Gross motor skills Gait Balance Posture & alignment 7

3/9/2018 How are therapy services determined? Classification of Cerebral Palsy OT and PT Evaluation • Standardized Assessments • Gross Motor Function Classification System • Gross Motor Function Measure (GMFM) (GMFCS) • Peabody Developmental Motor Scales (PDMS) • Manual Ability Classification System (MACS) • Beery-Buktenica Developmental Test of Visual Motor Integration (VMI) • Communication Function Classification System • Bruininks-Oseretsky Test (BOT) of Motor (CFCS) Proficiency • Canadian Occupational Proficiency Measure (COPM) • Functional Improvement Scale (FISC) How are therapy services determined? Individualized therapy plans OT and PT Evaluation • Hands on treatment • Home and School • Goals activities visit • Child and Parent • Co-Treatment • Durable Medical • Consultation • Functional Equipment • Monitoring • Orthoses • Canadian Occupational Performance • Intensive Treatment • Frequency Measure (COPM) • Home activity program 8

3/9/2018 Determining Therapy Frequency Medical therapy conference • Motivation • Emerging skill • Cognition • Change in status: growth spurt, hospitalization, • Parent Involvement seizures • Progress/Regression • Shift in age expected • Complexity/Multiple skills needs • Equipment needs • Age • Home Program training Developmental Pediatrics • Recent • Specific Goal procedure/surgery Physiatry • Rate of change • Participation Orthopedics • Maturity • Diagnosis Medical therapy conference Medical therapy conference • Every 6 months for active therapy • Developmental pediatrician (birth to 6 • Every 12 months for monitoring years) • Determine medical eligibility at age 3 • Physiatrist (ages 7 to 11 years) • Supervise therapy program • Recommend durable medical equipment • Physiatrist (ages 12 to 21 years) • Referrals to specialists • Orthopedist (as appropriate) • Hip surveillance • Kaiser (birth to 21 years) • Transition planning 9

3/9/2018 Social Worker Parent liaison Durable medical equipment (DME) Orthotics clinics clinics 10

3/9/2018 Dental clinics ADL groups Exercise groups Prom 11

3/9/2018 Prom Meet Taylor Taylor Taylor • By 11 months: increased tone and reflexes in • 39 weeks gestation via C-section all extremities; asymmetrical use of hands due to decreased fetal movement • Diagnosed with cerebral palsy at 24 months • Low APGARs • Services through Early Start by 11 months • Fetal maternal hemorrhage • • Developmental specialist Very low hematocrit Picture of Taylor as a • newborn Global brain injury • Occupational therapist (OT) • Respiratory failure • Physical therapist (PT) • Seizures, pulmonary • CCS at 2 years 11 months hypertension, • OT thrombocytopenia, sepsis • PT • NICU 12 days 12

3/9/2018 Neurologic status Range of Motion and Strength • 8 year old with spastic quadriparesis • Tightness into shoulder flexion and • Increased tone in all four extremities abduction, supination, elbow extension, • Lower extremities > Upper hip abduction, hip extension, knee Current picture of Taylor in extension, dorsiflexion therapy extremities • Weakness in all four extremities and • Left > Right trunk • Difficulty dissociating: • Impaired balance reactions • Eyes from head • Impaired protective reactions • Right and Left lower extremities • Trunk and extremities • Impaired sensation: vestibular, tactile • Impaired visual motor skills • Possible seizures Posture Fine Motor Skills • Reaches over head without loss of • Sits independently with erect balance posture for 2 minutes • Difficulty with elbow extension, • Sits and rotates to either side supination, precise use of fingers (to right better than to left and hands • Postures with rounded spine; • Hypermobility of some joints with elbow, wrist, finger, hip, and hypomobility of others in her hands knee flexion; hip adduction • Recommended use of hand splints and internal rotation; plantar to improve fine motor function flexion 13