The comprehensive rehabilitation services (CRS) program helps consumers who
have traumatic brain injury (TBI) and traumatic spinal cord injury (SCI) improve
their ability to function independently in the home and the community, with a
focus on mobility, self-care, and communication. The program sponsors three core
services to address functional ability:
Traumatic brain injury (TBI) is an insult to the brain that is
- not degenerative or congenital; and
- caused by an external physical force, which may produce a diminished or
altered state of consciousness, resulting in
- temporary or permanent impairment of cognitive abilities and/or physical
functioning, and
- partial or total functional disability or psychosocial maladjustment.
Traumatic spinal cord injury (SCI) is an acute, traumatic lesion of
neural elements in the spinal canal, resulting in any degree of temporary or
permanent
- sensory or motor deficit, or
- bladder or bowel dysfunction
The spinal cord is the part of the central nervous system that extends
from the foramen magnum to the cauda equina. All nerve roots within the spinal
canal are included.
Unless stated otherwise, policies and procedures in other chapters of this
manual apply to the CRS program.
However, neither of the following two VR policies and procedures applies to
the CRS program:
- the requirement to determine eligibility within 60 days of the date of
application, and
- the presumption of eligibility for recipients of Social Security disability
benefits (Supplemental Security Income [SSI] or Social Security Disability
Insurance [SSDI])
When you consider policies in other chapters, substitute the term
"independent living," which applies to the CRS program, for terms such as
"vocational rehabilitation," "vocational," and "employment."
The CRS Individualized Written Rehabilitation Plan (IWRP) is the same as the
VR IPE, except for the goals and intermediate objectives on the CRS IWRP.
Fiscal policies for the CRS program are the same as those for the VR Program,
except the four fiscal policies listed under
9.16 CRS Procurement.
*CRS core services have maximum limits, and they are not subject to exception
by the area manager.*
*40 TAC Section 107.1209
In this chapter, "you" refers to the CRS counselor.
Authorized by the 72nd Legislature, 1991, the CRS program is funded with
court cost surcharges on state felony and misdemeanor convictions.
The initial contact date for CRS is the date the consumer who has TBI and/or
SCI (or the consumer's representative) first
- contacts DRS about services for TBI and/or SCI; or
- applies for another DRS program (that is, VR or ILS).
Use the initial contact date to determine whether DRS may sponsor the
following two CRS core services; DRS may sponsor:
- inpatient comprehensive medical rehabilitation services only when the
consumer's initial contact date is within one year after the date of injury, or
- outpatient therapy services only when the consumer's initial contact date is
within two years after the date of injury.
Only counselors designated to work in the CRS program are assigned to CRS
cases. A non-CRS counselor making initial contact with a CRS consumer must
- call the operations director for programs in the appropriate regional office
to get the designated CRS counselor's name, and
- refer the consumer to that CRS counselor.
(Revised
02/11)
Document in the electronic case management system the initial call or visit
to DRS. Complete the initial contact record and personal information screen
regardless of the consumer's current level of functioning. The electronic case
management system adds the consumer to the CRS Interest and Waiting List.
When a CRS consumer with a case previously closed ineligible or unsuccessful
reapplies for services for
- a new injury,
- complete a new profile,
- use the most recent initial contact date, and
- the system places the person's name on the CRS Interest and Waiting List.
- the same TBI and/or SCI,
- open a new case,
- use the earliest initial contact date from the previous case, and
- explain this in a case note.
As soon as you determine that a case is not warranted, close the initial
contact case as ineligible. This action removes the consumer's name from the CRS
Interest and Waiting List. In the CRS program, initial contact information is not automatically removed from the electronic case management system when no profile is completed.
Because the need for services is usually greater than the amount of available funds, CRS has an Interest and Waiting List for consumers. Consumers are served in the order in which their original CRS IWRP is written and signed.
A consumer is considered to be "waiting" for CRS funds when the IWRP is signed in the consumer case management system.
All other consumers are considered “interested.”
The Interest and Waiting List
- consists of CRS consumers in the electronic case management system, along
with their initial contact date; and
- is managed by the Central Office program specialist and CRS technician.
Refer to the operations director for programs any inquiries about a consumer's status on the Interest and
Waiting List from persons other than the consumer or the consumer's
representative.
While the consumer is on the Interest and Waiting List
- contact the consumer (and/or representative) at least every 30 days; and
- document in a case note
- whether the person is ready for services, and
- the anticipated types of services, or
- the reason the person is not ready for services.
(Revised 02/11,
09/11)
Only items and services listed in this section may be purchased while a consumer is on the Interest and Waiting List.
You may purchase medical records and assessments for all consumers on the Interest and Waiting List.
You may purchase the services below for consumers who have been determined eligible and experience the listed conditions:
- contractures that are expected to cause permanent damage (document in a case
note) if not treated in a timely manner; in which case,
- DRS may sponsor services to address only this need;
- the consumer is still on the Interest and Waiting
List for all other
purchased services; and
- services provided under this exception
- are included in the total limit of 120 hours of outpatient therapy; and
- may be provided without an IWRP; or
- violent behavioral dyscontrol to the extent that he or she risks significant
bodily harm, incarceration, or psychiatric commitment (document in a case note);
in which case,
- DRS may sponsor up to 14 days of inpatient medical behavior management at
- a comprehensive medical rehabilitation hospital specializing in brain
injury, or
- a residential post-acute brain injury rehabilitation facility;
- if necessary, the service may
- be extended for an additional seven days, and
- include medication, and as needed, medical follow-up appointments;
- the consumer is still on the Interest and Waiting
List for all other
purchased services; and
- services provided under this exception
- are included in the total limit of 90 days of inpatient rehabilitation or
six months of post-acute brain injury rehabilitation; and
- may be provided without an IWRP.
You may purchase case management services for consumers on the CRS Waiting List who have an IWRP. Generate a purchase order in anticipation of case management services soon after the IWRP is signed requiring direct communication between the CRS counselor and the MSC.
When funds become available and a consumer can be removed from the CRS Waiting List, Central Office programs staff or a designee must allocate funds for any services other than those itemized in this section.
(Revised 02/11)
The electronic case management system removes a person's name from the
interest and waiting list when
- you close the case, or
- the IWRP is signed, and funds for services, other than evaluation services
and services described in 9.5.2, are first allocated.
When you determine that a case is unwarranted, close the initial contact case
as ineligible.
(Revised 12/09,
03/10,
02/11)
The "Texas Residence" option in the electronic case management system is active for CRS cases. Select "Yes" or "No" to indicate whether the six-month Texas residency requirement has been established at application (see
9.7.1 Eligibility Requirements).
If you select "No," you may not determine that the consumer is eligible until he or she meets the residency requirement, at which time you must update the screen.
Forms are signed to permit the exchange of information needed during the rehabilitation process. These forms are the same as those used for the VR program. See
Chapter 2: Initial Contact and Application, 2.4.7 Forms to Be Signed at
Application.
Determine eligibility for services without regard to sex, race, religion,
color, and national origin.
The 60-day limit for determining eligibility does not apply to CRS. See
CRS Determining Eligibility.
The consumer must
- *have a TBI and/or SCI that results in a substantial impediment to
functioning independently in the home and the community in terms of
- mobility,
- self-care, and/or
- communication;
- be at least 15 years of age;
- be a citizen or immigrant alien of the United States;
- be a resident of Texas for at least six months, or have a family member
living in the state for at least six months who is, or will become, the
consumer's primary caregiver;
- be sufficiently medically stable to participate actively in the program;
- be willing to accept treatment; and
- not be in the "eligibility," "plan initiated," or "post-closure services"
phase of another DRS program.*
*40 TAC Section 107.1203
Exception: A consumer who meets the eligibility requirements for the
DBS independent living services (ILS) program and the DRS CRS program may
receive services from both programs concurrently.
You must reasonably expect that having received CRS program core services,
the consumer will be able to function more independently in the home and the
community.
When you help a consumer make an informed choice about residing in an
institution, including a nursing home, you must inform the person about any
community support that may help him or her function in the most independent
setting possible.
You must
- provide information regarding community-based services, and
- document the action in a case note, as appropriate.
For more information, see Chapter 4: Assessing and
Planning, 4.7 Providing Community-Based Service Information.
A consumer who requires ongoing services (for example, personal attendant
services, medications, medical supplies) is not eligible for CRS if
- resources for these services cannot be identified, and
- the consumer cannot function more independently without them.
When a consumer has a second TBI and/or SCI, the consumer may
- reapply for CRS; and
- be eligible for the full complement of services, regardless of any services
he or she previously received.
(Revised 03/09,
02/11)
When documentation from the consumer's treatment providers is not conclusive, begin assessments necessary to help determine eligibility. You may spend funds for assessment activities without removing the consumer from the interest and waiting list.
The eligibility evaluation must include
- an appraisal of the consumer's general medical condition,
- documentation of a TBI and/or SCI,
- a determination of whether the consumer is medically stable enough to actively participate in planned services, and
- your appraisal of psychological and other factors that relate to the consumer's ability to participate in planned services (a psychological or neuropsychological evaluation may be needed, but is not required).
See Chapter 3: Eligibility, 3.8 Required Assessments and Policies for
Selected Disabilities,
Traumatic Brain Injury (TBI) and
Spinal Cord Injury (SCI).
Eligibility Evaluation and Assessments
To determine whether a consumer is eligible,
- evaluate the consumer to the degree necessary to determine eligibility and
to plan services; and
- obtain existing medical and psychological records (when records are
unavailable or inadequate, purchase assessments as necessary).
Do not use CRS funds to pay for assessments that require inpatient
hospitalization.
To determine eligibility or plan services for another DRS program, pay for
assessments with funds from that program (see
example).
When you can presume that a consumer is capable of achieving an employment
outcome, close the CRS case and open a VR case.
Eligibility Statement
(Revised 02/11)
If the consumer meets CRS eligibility criteria, complete DARS5107, Comprehensive Rehabilitation Services Eligibility Statement.
Ineligibility Letter
(Revised 02/11)
If the consumer does not meet CRS eligibility criteria,
- check the appropriate box on DARS5108, CRS Ineligibility Letter; and
- give the consumer a copy of the letter.
Except for CRS IWRP goals and intermediate objectives, the IWRP is the same
as the VR IPE (see Chapter 4: Assessing and Planning, 4.4
Developing the IPE).
Select one or more of the following independent living goals:
- increased ability to perform self-care activities,
- increased mobility, and/or
- increased ability to communicate with others.
Services listed on the IWRP must clearly support the achievement of consumer
goals.
Document the consumer's informed choice in a case note (see
example).
Use the following procedure to develop the IWRP:
- before beginning services, complete a
DARS5164, Comprehensive Rehabilitation Services, Individualized Written Rehabilitation Plan (IWRP) with the consumer (and/or consumer's representative);
- review the IWRP with the consumer (and/or the consumer's representative) at least annually, near the anniversary date;
- as necessary, amend the IWRP with the consumer (and/or the consumer's representative) using the
DARS5160, Comprehensive Rehabilitation Services, Individualized Written Rehabilitation Plan (IWRP) Amendment; and
- give a copy of the IWRP, along with other referral information, to the identified provider of post-acute brain injury rehabilitation to help coordinate services between the consumer, provider, and DRS.
After you complete the IWRP, you or the MSC develop service records to help
you
- plan, and
- determine projected costs.
Service records can be
- saved without a provider or type service, and
- updated later to generate the purchase order.
Handle CRS service records the same way as VR service records. See
Chapter 7: Purchasing, 7.5.4 Service Records for more
information.
Before using CRS funds, use comparable services and benefits.
Do not delay services while an application for comparable services and
benefits is pending.
After a plan has been initiated, and before you provide any purchased
services to a consumer who has a TBI, *the consumer must be functioning at or above Level
IV of the Rancho Los Amigos Levels of Cognitive Functioning Scale, or equivalent.*
*40 TAC Section 107.1209(8)
When medical services providers do not clearly indicate the Rancho Level, you
may
- review the medical records with the local medical consultant or other
medical professional, and
- determine the level.
Inpatient comprehensive medical rehabilitation services
- *may be sponsored only when there is no more than one year between the date
of injury and the date of initial contact,*
- are indicated on the IWRP as "up to 30 days of services," and
- *may be extended to a maximum of 90 days* without an IWRP amendment when
recommended by the inpatient interdisciplinary team.
*40 TAC Section 107.1209(1)(A) and (1)(D)
An interdisciplinary team of professionals closely coordinates services to
achieve team treatment goals in order to
- minimize a person's physical or cognitive disabilities, and
- maximize a person's functional capacity.
The 90-day limit on inpatient comprehensive rehabilitation services is
measured from the first day of services sponsored by DRS. When a facility
divides its program into phases and discharges the consumer for a period before
bringing the consumer back to complete the program,
- DRS may sponsor both periods of hospitalization up to a cumulative total of
90 days, and
- no more than six months may lapse between discharge from the program's first
phase and entry into its second phase.
When necessary, and within the 90-day time limit, a comprehensive hospital
day-treatment program may be used.
Inpatient comprehensive medical rehabilitation services
Outpatient therapies
- must be prescribed by a physician,
- *may be sponsored only when there is no more than two years between the date
of injury and the date of initial contact, and
- are limited to a maximum of 120 hours.*
*40 TAC Section 107.1209(2)(A) and (2)(B)
Therapy (any combination) includes
- physical,
- occupational,
- speech, and
- cognitive rehabilitation.
When necessary, provide physician follow-up visits, not included in the
120-hour limit of services.
Outpatient therapy services
(Revised 12/08)
Post-acute brain injury (PABI) rehabilitation services (residential or
nonresidential)
- *are not limited by the time passed since onset of injury;*
- are indicated on the IWRP as “up to three months of services”;
- may be extended month to month, *up to a maximum of six months,* without an IWRP amendment, when recommended by the PABI interdisciplinary team; and
- include a goal of increasing the consumer's ability to function as
independently as possible.
*40 TAC Section 107.1209(3)
When necessary to achieve a consumer's independent-living goals, and as
indicated in the IWRP, DRS may sponsor
- physical therapy,
- occupational therapy, and/or
- speech therapy.
While the consumer is receiving PABI rehabilitation services, individual
therapies
- must be prescribed by a physician,
- may be sponsored as long as the consumer is increasing in ability to
function in the home and community, and
- may be provided in addition to any "outpatient services" or "inpatient
services" previously sponsored by the CRS program.
The six-month limit on PABI rehabilitation services is measured from the
first day of services sponsored by DRS. When a PABI rehabilitation facility
divides its program into two phases and releases the consumer for a period
before bringing the consumer back to complete the program, DRS may sponsor both
periods of PABI services up to a cumulative total of six months.
When a consumer is receiving PABI rehabilitation services
- cognitive therapy is provided as part of the interdisciplinary team
approach;
- usually, DRS does not sponsor individual cognitive therapy in addition to
PABI rehabilitation services;
- a case note must explain any unusual need for cognitive therapy; and
- additional cognitive therapy requires the area manager's approval.
Give a copy of the IWRP, along with other referral information, to the PABI
rehabilitation services providers to help coordinate services between the
consumer, providers, and DRS.
(Revised 02/11)
Use only DRS-approved providers of PABI rehabilitation services. To find a provider,
- create a service record (use Residential Rehabilitation Services; Room, Board, and Supervised Living for the Level 1 specification); and
- use the "Go to Vendor Search" option to select an approved provider.
Provide counseling and guidance to the consumer and family throughout the
program to help the consumer achieve independent-living goals. Counseling and
guidance includes providing information and helping the consumer and family
- understand the rehabilitation process,
- determine appropriate types of services,
- make informed choices,
- select providers,
- arrange for admission to a program,
- overcome or adjust to any problems while in the program,
- understand the consumer's long-term needs, and
- plan for discharge.
(Revised 12/08)
Plan the following goods and services on the IWRP in support of a CRS core
service. You may provide these services as needed to the consumer during
participation in a core service:
- drugs, rehabilitation technology, and medical equipment and supplies;
- rehabilitation medical procedures;
- orthotics and prosthetics;
- personal attendant services;
- psychological services; and
- transportation.
(Revised 12/08)
After using available comparable benefits, provide drugs, rehabilitation
technology, and medical equipment and supplies while the consumer participates
in rehabilitation services. At discharge from the facility, when necessary,
provide, *but do not exceed, a 30-day supply of drugs and medical supplies.*
*40 TAC Section 107.1209(4)
The CRS program sponsors rehabilitation medical procedures that are expected
to help increase the consumer's functional ability.
Acute medical care may be sponsored only for an inter-current illness
- that interferes with the consumer's ability to continue in rehabilitation
services, and
- when services of short duration are expected to help the consumer continue
in or return to rehabilitation services.
When a consumer needs emergency care or treatment for a medical condition
that requires extensive or ongoing care, use the consumer's other resources
including
- Medicare,
- Medicaid,
- insurance,
- workers' compensation,
- indigent health services, and
- county hospitals.
Provide devices, including mobility and self-help aids, when these devices
are essential to achieving the consumer's IWRP goals.
Provide personal attendant services only when necessary to enable the
consumer to participate in CRS core rehabilitation services.
Provide psychological services within the guidelines of
Chapter 5: Services, 5.3.6 Mental Restoration Services, as part of the 120
hours of outpatient therapy.
Limit transportation to helping
- the consumer get to and from service facilities, and
- family caregivers travel to and from treatment facilities to participate in
specific training that addresses the consumer's rehabilitation needs.
(Revised 02/11)
Before using CRS funds, use comparable services and benefits.
The priority for using CRS funds is
- consumers now receiving CRS,
- assessments for consumers on the interest and waiting list, and
- all other consumers on the interest and waiting list who are ready for
services.
With the exception of the following four items, fiscal policies for the CRS
program are the same as the VR program:
- Designated CRS counselors, RSTs, MSTs, and MSCs may issue purchase orders
for CRS expenses.
- For a consumer on the CRS Interest and Waiting List who becomes ready for
services, only Central Office programs staff or designee may allocate funds for
services other than medical records or assessments.
- Because state funds are used for this program, services may be authorized
only until August 31 of the state fiscal year in which the funds are obtained.
Purchase order end dates may not extend beyond August 31 of the fiscal year in
which the service is authorized.
- Obtain CRS funds by consulting with MSCs. Funds are allocated, case by case,
using “Case Funds” actions assigned to the designated Central Office CRS program
specialist or administrative technician.
Post-closure services, when combined with services previously provided, must
not exceed the following time limits.
| Services |
Time Limit |
|
*Inpatient comprehensive medical rehabilitation*
|
*90 days*
|
|
*Outpatient comprehensive rehabilitation*
|
*120 hours*
|
|
*Post-acute brain injury rehabilitation*
|
*6 months*
|
*40 TAC Section 107.1209
To provide time-limited post-closure services, one of the following criteria
must be met:
- a planned service was inadvertently not provided before case closure;
- the consumer did not receive the full complement of CRS, and you later
determine that the consumer could benefit from post-closure services; or
- post-closure services are needed to protect DRS' initial investment (see
example).
(Revised 02/11)
When the IWRP does not list post-closure services, complete an IWRP
amendment.
Notify the consumer of case closure with a DARS5210, CRS Successful Closure letter.
The CRS program does not provide
- assessments that require inpatient hospitalization,
- assessments to determine eligibility or plan services for another DRS
program,
- acute and/or extended general medical care,
- driving evaluations and/or vehicle modifications,
- vocational services of any kind, and
- services to groups of persons with disabilities.
You must ensure that the consumer is benefiting from treatment. You are a
member of an interdisciplinary treatment team and should, whenever possible,
participate in treatment team meetings to follow the consumer's progress. If you
cannot be present, consider teleconferencing.
When a rehabilitation treatment is not leading to increased independence, you
should work with the treatment team to consider changes that make the treatment
more beneficial. When this is not possible, you should discontinue sponsorship
of the treatment.
When complex issues evolve and treatment providers are distant from your
office, you may request that the DRS liaison counselor to the facility or a
medical services coordinator be present at a particular meeting.
Contact the consumer (and/or consumer's representative) at least every 30
days throughout the life of the case.
During service provision when a consumer becomes eligible for the VR program,
- close the CRS case,
- return all unused funds to the state contingency fund, and
- shift sponsorship to the appropriate program.
When necessary to help provide services (for example, when the consumer has
moved, the consumer is changing from VR to CRS),
Regardless of the type, case files must substantiate the closure, documenting
- the reason for closure, and
- justification.
An annual review of closed cases is not required.
Close a case as successful when
- the IWRP is completed as much as possible,
- services provided substantially improved the consumer's ability to function
independently in the home and the community, and
- documentation in the case file shows how the consumer is able to function
more independently as a result of the services provided.
Notify the consumer by personal contact, telephone, and/or in writing that
the case is closed.
Before you close a CRS counseling-only case as successful, the consumer must
have received treatment, as a comparable benefit or an arranged service, from
- inpatient hospitalization,
- outpatient services, and/or
- PABI rehabilitation services.
If counseling is the only CRS service provided, explicitly document in the
case file that
- the consumer received substantial counseling;
- the counseling helped the consumer function more independently in terms of
- mobility,
- self-care, and/or
- communication; and
- the counseling helped the consumer and family
- select and/or maintain suitable, realistic independent living goals;
- select suitable treatment providers and use comparable benefits;
- adjust to treatment, as circumstances required; and/or
- access any relevant support services.
(Revised 02/11,
09/11)
End services and close the case in the appropriate unsuccessful status when
you determine that the consumer cannot
- benefit substantially from CRS, and
- improve his or her ability to function more independently in the home and
the community.
Make this decision only after
- considering all the facts and circumstances, and
- exhausting every appropriate resource and service.
When, for any reason, you close a case as "unsuccessful" or "ineligible," and
later the consumer comes back for CRS for the same injury,
- open a new case, and
- use the initial contact date from the previous TBI and/or SCI case.
Identify the reason the case was closed and procedure for closing.
|
Reason Closed
|
Procedure
|
|
Severity of the Disability
You determine that the severity of the disability prevents CRS from helping
the person function more independently in the home and the community.
|
Notify the consumer that the case is closed.
Use the DARS5214, CRS Unsuccessful Closure letter to advise the consumer in writing of the decision and, if appropriate, refer him or her to another agency.
|
|
Other
Services may be denied or ended for reasons other than those described in
this list.
|
Describe the reason for closure in a case note.
Notify the consumer that the case is closed.
Use the DARS5214, CRS Unsuccessful Closure letter to advise the consumer in writing of the decision and, if appropriate, refer him or her to another agency
|
|
Unable to Locate or Moved out of State
|
Document
- repeated attempts by telephone and mail, over a reasonable period, to
contact the consumer, family, or references; and/or
- that the person moved out of state and the reason you believe there is no
evidence that the person is going to return.
|
|
Consumer Is Not Functioning More Independently
(valid after eligibility) You cannot verify that the consumer is functioning
more independently in the home and community.
|
Notify the consumer that the case is closed.
Use the DARS5214, CRS Unsuccessful Closure letter to advise the consumer in writing of the decision and, if appropriate, refer him or her to another agency.
|
|
CRS Not Required
The consumer
- does not need CRS to function more independently in the home and community;
- already is receiving needed services, or services are readily available,
without DRS arranging, coordinating, paying for, and/or providing the services;
or
- does not need DRS counseling and guidance.
|
Notify the consumer that the case is closed.
Use the DARS5214, CRS Unsuccessful Closure letter to advise the consumer in writing of the decision and, if appropriate, refer him or her to another agency.
|
|
Refused Services
The consumer clearly does not intend to follow through with the program.
|
Be certain that the consumer
- knows about available services, and
- persistently refuses services.
Notify the consumer that the case is closed.
Use the DARS5214, CRS Unsuccessful Closure letter to advise the consumer in writing of the decision and, if appropriate, refer him or her to another agency.
|
|
Failure to Cooperate
The consumer fails to follow through with the program.
|
Document examples of failure to cooperate. Notify the consumer of
- your intent to close case, and
- his or her right to appeal.
Use the DARS5214, CRS Unsuccessful Closure letter to advise the consumer in writing of the decision and, if appropriate, refer him or her to another agency.
|
|
Institutionalized
The consumer
- entered an institution (for example, hospital, nursing home, treatment
center);
- will not be available for services for an indefinite or considerable time;
and
- certainly will not benefit from keeping the case open.
|
Provide information about community-based services, and document the action
in a case note, as appropriate.
For more information, see
Chapter 4: Assessing and Planning,
4.7 Providing Community-Based Service Information.
Notify the consumer that the case is closed.
Use the DARS5214, CRS Unsuccessful Closure letter to advise the consumer in writing of the decision. Describe the circumstances in the case notes.
|
|
Death
|
No notification is necessary. You are required to contact the family only if DRS can reclaim equipment that was purchased. Be sensitive and minimize disruption to the family caused by reclaiming the equipment. Consult with the Central Office program specialist for rehabilitation technology about which items to reclaim.
|
|
Transferred to Another Agency or DRS Program
|
When it is apparent that services from another DRS program or another agency
are more appropriate than CRS,
- discuss the transfer with the consumer;
- discuss the case with the other DRS program's counselor; or
- if appropriate, set up an appointment for the consumer with the other
agency; and
- provide the other agency with any appropriate information requested.
Notify the consumer that the case is closed.
Use the DARS5214, CRS Unsuccessful Closure letter to advise the consumer in writing of the decision. Describe the reasons for transfer in case notes.
|
Level I: Generalized
Patient appears to be in a deep sleep and is completely unresponsive to any
stimuli.
Level II: Generalized Response
- Patient reacts inconsistently and nonpurposefully to stimuli in a
nonspecific manner.
- Responses are limited in nature and are often the same regardless of
stimulus presented.
- Responses may be
- physiological changes,
- gross body movements, and/or
- vocalization.
- Often the earliest response is to deep pain.
- Responses are likely to be delayed.
Level III: Localized Response
- Patient reacts specifically but inconsistently to stimuli.
- Responses are directly related to the type of stimulus presented as in
- turning head toward a sound, and/or
- focusing on an object.
- May withdraw an extremity and/or vocalize when presented with a painful
stimulus.
- May follow simple commands in an inconsistent, delayed manner, such as
- closing the eyes,
- squeezing, and/or
- extending an extremity.
- Once external stimulus is removed, patient may lie quietly.
- May show a vague awareness of self and body by responding to discomfort by
- pulling at nasogastric tube or catheter, and/or
- resisting restraints.
- May show a bias by responding to some persons (especially family or
friends), but not to others.
Level IV: Confused-Agitated
- Patient is in a heightened state of activity with significantly decreased
ability to process information.
- Is detached from the present and responds primarily to own internal
confusion.
- Behavior is frequently bizarre and nonpurposeful, relative to immediate
environment.
- Patient may
- cry or scream out of proportion to stimuli, even after removal;
- show aggressive behavior;
- attempt to remove restraints, tubes; and/or
- crawl out of bed in a purposeful manner.
- Patient does not discriminate among persons or objects and is unable to
cooperate directly with treatment efforts.
- Verbalization is frequently incoherent and/or inappropriate to the
environment.
- Confabulation may be present.
- May be euphoric or hostile, thus gross attention to environment is short and
selective attention is often nonexistent.
- Being unaware of present events, patient lacks short-term recall and may
react to past events.
- Is unable to perform self-care (feeding, dressing) without maximum
assistance.
- If not physically disabled, patient may perform motor activities such as
sitting, reaching, and ambulating, as part of the patient's agitated state and
not necessarily as a purposeful act or upon request.
Level V: Confused, Inappropriate Non-Agitated
- Patient appears alert and is able to respond to simple commands fairly
consistently.
- With increased complexity of commands or lack of any external structure,
responses are nonpurposeful, random, or at best fragmented toward any desired
goal.
- May show agitated behavior, but not an internal basis (as in Level IV), but
rather as a result of external stimuli, and usually out of proportion to the
stimulus.
- Has gross attention to task without frequent redirection back to it.
- With structure, patient may be able to converse, or confabulation may be
triggered by present events.
- Memory is significantly impaired, with confusion of past and present in
patient's reaction to ongoing activity.
- Lacks initiation of functional tasks and often shows inappropriate use of
objects without external direction.
- May be able to perform previously learned tasks when structured for patient,
but is unable to learn new information.
- Responds best to self, body, comfort, and often to family members.
- Can usually perform self-care activities with assistance and may accomplish
feeding with maximum supervision.
- Management on the ward is often a problem when the patient is physically
mobile, as patient may wander off either randomly or with vague intention of
"going home."
Level VI: Confused-Appropriate
- Patient shows goal-directed behavior, but is dependent on external input for
direction.
- Response to discomfort is appropriate, and patient is able to tolerate
unpleasant stimuli (as naso-gastric tube) when need is explained.
- Follows simple direction consistently and shows carryover for task patient
has relearned (as self-care).
- Is at least supervised with old learning; unable to maximally assist for new
learning with little or no carryover.
- Responses may be incorrect because of memory problems, but they are
appropriate to the situation.
- Responses may be delayed to immediate, and patient shows decreased ability
to process information with little or no anticipation or prediction of events.
- Past memories show more depth and detail than recent memory.
- May show beginning immediate awareness of own situation by realizing he or
she doesn't know an answer.
- No longer wanders and is consistently oriented to time and place.
- Selective attention to tasks and in unstructured settings but is now
functional for common daily activities (30 minutes with structure).
- Shows at least vague recognition of some staff, has increased awareness of
self, family, and basic needs (as food) again in an appropriate manner as in
contrast to Level V.
Level VII: Automatic-Appropriate
- Patient appears appropriate and oriented within hospital and home settings.
- Goes through daily routine automatically, but frequently robot-like, with
minimal to absent confusion, but has shallow recall of what he or she has been
doing.
- Shows increased awareness of self, body, family, foods, people, and
interaction in the environment.
- Has superficial awareness of, but lacks insight into, his or her condition;
demonstrates decreased judgment and problem solving; and lacks realistic
planning for future.
- Shows carryover for new learning, but at a decreased rate.
- Requires at least minimal supervision for learning and for safety purposes.
- Is independent in self-care activities and supervised in home and community
skills for safety.
- With structure, is able to initiate tasks such as social or recreational
activities in which he or she now has interest.
- Judgment remains impaired such that patient is unable to drive a car.
- Prevocational or a vocational evaluation and counseling may be indicated.
Level VIII: Purposeful and Appropriate
- Patient is alert and oriented.
- Is able to recall and integrate past and recent events and is aware of and
responsive to his or her culture.
- Shows carryover for new learning if acceptable to patient and his or her
life role, and needs no supervision once activities are learned.
- Within patient's physical capabilities, is independent in home and community
skills, including driving.
- Vocational rehabilitation, to determine ability to return as a contributor
to society (perhaps in a new capacity), is indicated.
- May continue to show a decreased ability, relative to pre-morbid abilities,
reasoning, tolerance for stress, and judgment in emergencies or unusual
circumstances.
- Social, emotional, and intellectual capacities may continue to be at a
decreased level for patient, but are functional for society.