Red Flags for Care Planning OM Reference Guide
Red Flags for Care Planning OM Reference Guide
Red Flags for Care Planning OM Reference Guide
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<strong>Red</strong> <strong>Flags</strong> <strong>for</strong> <strong>Care</strong> <strong>Planning</strong><br />
Outcome Measure <strong>Reference</strong> <strong>Guide</strong><br />
For Use with Acute Stroke Discharges<br />
Domain Outcome Measure <strong>Red</strong> Flag<br />
Score<br />
Functional<br />
Independence<br />
Cognition /<br />
Perception<br />
Balance<br />
Emotion<br />
Communication<br />
Dysphagia<br />
(Swallowing<br />
Difficulties)<br />
/ Nutrition<br />
RAI<br />
Or Clinical Documentation of:<br />
ADL and mobility challenges<br />
impacting function Implication of<br />
deficits below<br />
Poor management of medications,<br />
new learnings re meds (e.g., insulin)<br />
Issues relating to family dynamics<br />
Social issues<br />
Financial issues<br />
MoCA<br />
MMSE<br />
Clock Draw<br />
Trails A<br />
Trails B<br />
Or Clinical Documentation of:<br />
Visual/spatial perceptual deficits<br />
with neglect; insight/judgment;<br />
attention; memory;<br />
apraxia/planning;<br />
BERG = limited outdoor ambulation<br />
BERG = risk of falls<br />
Or Clinical Documentation of:<br />
poor balance<br />
BASDEC<br />
Or Clinical Documentation of:<br />
<strong>Care</strong>giver at risk <strong>for</strong> depression /<br />
psychosocial issues<br />
Confirmed depressed, poor<br />
motivation, lethargy, history of<br />
thoughts of suicide<br />
LAST<br />
FAST<br />
Or Clinical Documentation of:<br />
Or clinical indications (expressive<br />
difficulties, word finding, difficulty<br />
naming common objects, difficulty<br />
following directions, poor speech<br />
intelligibility)<br />
STAND<br />
TORBSST<br />
Or Clinical Documentation of:<br />
Coughing, choking, wet voice,<br />
drooling<br />
MNA<br />
Or Clinical Documentation of:<br />
Weight loss, signs of dehydration,<br />
slow intake, diabetes<br />
‘At Risk’<br />
< 25<br />
< 23<br />
Errors<br />
>79 secs<br />
>3 mins or<br />
1 error<br />
< 50<br />
< 45<br />
> 7<br />
“Fail”<br />
“Fail”<br />
“Fail”<br />
“Fail”<br />
< 11<br />
CC Referral<br />
Considerations<br />
CCAC CC community<br />
assessment to prevent or<br />
stabilize early health or<br />
functional decline<br />
Interprofessional referrals to<br />
rehab therapies (PT, OT, SLP,<br />
SW), Nursing, Registered<br />
Dietitian as indicated<br />
OT referral through CCAC<br />
Advise not to drive without<br />
discussion with family physician<br />
(may need referral <strong>for</strong> driving<br />
assessment)<br />
See website:<br />
http://www.mto.gov.on.ca/english/dan<br />
dv/driver/medical-review/evalcentres.shtml<br />
PT referral through CCAC<br />
Query OT referral through<br />
CCAC <strong>for</strong> safety and home<br />
assessment<br />
SW referral through CCAC<br />
Refer to Community Supports<br />
(e.g., Stroke Survivor Group)<br />
Reevaluation at intervals post<br />
stroke<br />
SLP referral through CCAC<br />
SLP referral through CCAC <strong>for</strong><br />
dysphagia assessment<br />
RD referral through CCAC <strong>for</strong><br />
nutrition assessment<br />
Acronym Legend
Acronym Legend<br />
ADL – Activities of Daily Living<br />
CC – <strong>Care</strong> Coordinator<br />
OT – Occupational Therapist<br />
RN – Registered Nurse<br />
RD – Registered Dietitian<br />
PT – Physiotherapist<br />
SW – Social Worker<br />
SLP – Speech-Language Pathologist<br />
RAI – Resident Assessment Instrument (Assessment tool <strong>for</strong> Functional Independence)<br />
MoCA – Montreal Cognitive Assessment (Cognitive Screening tool)<br />
MMSE – Mini Mental State Examination (Cognitive Screening tool)<br />
BERG – BERG Balance Scale (Assessment tool <strong>for</strong> static and dynamic balance)<br />
BASDEC – Brief Assessment Schedule Depression Cards (Depression Screening tool)<br />
LAST – The Language Screening Test (Language Screening tool)<br />
FAST – Frenchay Language Screening Test (Language Screening tool)<br />
STAND – Screening Tool <strong>for</strong> Acute Neurological Dysphagia (Swallowing Screening tool)<br />
TOR-BSST © - Toronto Bedside Swallowing Screening Test (Swallowing Screening tool)<br />
MNA – Mini Nutritional Assessment (Nutrition Screening tool)<br />
Rev. Mar. 2013
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