Completing Cells on the Grid

Definition of Risk Value within each domain, barriers to improvement are assessed reviewing past history current problems and potential threat or life risk.  During the assessment process, these areas are explored with the patient and based on the presence and severity of risk, a score, or value is given to each area.  The values range from ‘0’ or no risk to ‘3’ significant risk.  These scores are totaled to provide the ICM-CAG total score which assists in determining the level of complexity and determination of what areas require immediate attention in the care planning process.

 

Biological Domain

 

Chronic Illness: scores are based on any periods of physical complainats, discomfort, symptoms or disease present for 5 years.  Eg. Chest pain, SOB, HA’s, presence of chronic diseases like diabetes, Lupus, or CAD.

 

Diagnostic Difficulty: history of physical complaints that have not been attributed to a specific condition, or have not been addressed by providers.  The reported signs/symptoms may wax/wane; testing may have been done with no definitive diagnosis.  Eg. Chest pain, SOB, back pain.

 

Symptom Severity: compare symptoms and complaints to any existing impairment or decrease in function. Eg. SOB prevents ability to walk 50 ft., non-healing foot ulcer prevents return to work.

 

Adherence Ability: presence of complaints and/or symptoms for which association with a specific condition or diagnosis is not present. CMs are not responsible for diagnosing illness, but understanding signs/symptoms unconnected to a specific condition can initiate discussions with a Medical Director or PCP, or may result in exploration of mental health issues.  Eg. Chronic pelvic pain, dizziness, back pain that has not responded to EB interventions.

 

Complications and Life Threat: clinical judgment is used to measure both historical and current physical issues to determine the risk of recurrence, worsening symptoms or further impairment.

 

Psychological Domain

 

Barriers to Coping: evaluation of an individual’s ability or approach to dealing with problems to see   how an individual reacts to life issues, illness limitations and ability to participate in their own care.  Eg. Cognitive impairment, personality disorder, substance use/abuse.

 

Mental Health History: any history of mental health issues over the lifetime of the patient need to be considered.  Past psychiatric issues are indicative of the potential for future difficulties. Eg. Female with history of postpartum depression is at risk of depression while battling breast cancer.

 

Resistance to Treatment: evaluation of a patient’s willingness and/or ability to comply with prescribed treatment.  Cultural or religious beliefs, or low health literacy could interfere with any prescribed treatment plan.  Eg. May not like to take meds, prefers homeopathic approach, cultural beliefs in direct conflict with Western or traditional medicine.

 

Mental Health Symptoms: important to determine the presence of serious psychiatric conditions versus milder symptoms.  Individuals with substance abuse, schizophrenia, or bipolar disorder exhibiting paranoia, delusions or hallucinations should be attended by a psychiatrist.  Presence of anxiety, difficulty concentrating, feeling blue, or occasionally drinking too much will require involvement of focused mental health services.

 

Mental Health Threat: clinical judgment is used to determine the potential for worsening mental health signs/symptoms based on history and current state.  The intent is to protect the patient from deteriorating while preparing the patient or caregiver to resume responsibility for stability.  Eg. hallucinations, paranoia versus feeling anxious or sad.

 

Social Domain

 

Job and Leisure: assessment of personal and social successes in employment, interactions with others, and participation in activities that provide personal enjoyment.  Spending time in passive activities or poor work performance, indicate a concern with improved overall health outcome. Only watches TV or plays video games, on temporary disability.

 

Relationships: presence of conflicted relationships with family, friends, or co-workers demonstrate risk of complexity.  Absence of functional relationships leads to isolation or feelings of abandonment.  Eg. Argumentative, physically aggressive, unable to get along with others.

 

Residential Stability:  assessing if patient has a stable place to live, is able to pay rent or mortgage, is safe from harm.  Eg. Homeless, in abusive relationship, concerns with making the rent /mortgage.

 

Social Support: determine who is available to help and support patient when having difficulties. Eg. No family close by, speak a different language, little or no socialization outside home.

 

Social Vulnerability: determine form current and historical items if the patient is at risk for worsening health issues due to poor support, isolation, or unstable environment.

 

Health System Domain

 

Access to Care: the presence of system-level difficulties that prevent a patient from receiving needed care and services.  Eg., no insurance, insurance coverage with limitations, living in a rural area with few practitioners, financial concerns that limit out-of-pocket expenses, cultural or language barriers.

 

Treatment Experience: past experience with healthcare professionals that has been less than optimal may impact how well a patient will engage in care going forward.  Also consider experiences by a patient’s family and friends, as well as a general negative impression about healthcare providers.  Eg., distrust of doctors, multiple providers for the same health problem, frequent ER visits, forced to stay with an undesirable provider.

 

Getting Needed Services: assess the patient’s ability to practically access care from the appropriate practitioners and benefit/insurance coverage. 

Considerations should include appropriate practitioner with close geographic proximity, access to transportation, adequate insurance/financial resources to pay for care, ability to schedule timely appointments.

 

Provider Collaboration: patients that are seeing multiple providers are likely receiving care and services that are not well communicated among the providers.  This is often the case when a patient is seen by a PCP and psychiatrist.  Commonly, the two physicians do not share information, such as prescriptions ordered.  Another challenge can be seeing practitioners from different health systems; it is very likely that no information is shared.  Eg., duplication of diagnostic tests, redundant prescriptions.

 

Health System Deterrents: concern for past or persistent poor doctor-patient relationships and inability to navigate the healthcare system.  Without intervention, improvements in health outcomes are unlikely.