Download RESPONSE TO THE FINAL REPORT OF THE CATASTROPHIC IMPAIRMENT EXPERT PANEL

RESPONSE TO THE FINAL REPORT OF THE
CATASTROPHIC IMPAIRMENT EXPERT PANEL
MAY 13, 2011
The Ontario Society of Occupational Therapists (OSOT) has reviewed the Final Report of the
Catastrophic Impairment Expert Panel to the Superintendent, “Recommendations for Changes
to the Definition of Catastrophic Impairment”, April 8, 2011. Our response to the proposed
recommendations has been carefully considered by occupational therapists who have been
involved in the catastrophic determination assessment process and who are experienced in
assessing and treating adults and children with catastrophic and non-catastrophic injuries as
defined by the Statutory Accident Benefits Schedule (SABS).
The Society recognizes the mandate of the Expert Panel to review the definition of
“catastrophic impairment” located in the SABS and to make recommendations for changes to
the definition to ensure that the most seriously injured accident victims are treated
appropriately. The Society has approached its review of the Panel‟s recommendations
primarily with concern for, and attention to, the goal of assuring access to appropriate care
and treatment for the most seriously injured.
The Society understands that the Expert Panel developed its recommendations giving
precedence to scientific evidence and judgment. While respectful of and acknowledging the
relevance of science to outcomes, the Society forwards an insight into the dynamic nature and
realities of the health system in which Ontarians injured in motor vehicle accidents experience
treatment, rehabilitation and care through the lens of occupational therapists working in the
clinical field. It is our hope that these insights will complement and augment the scientific
basis of the recommendations of the Expert Panel, and ultimately, will contribute to a more
equitable process for the determination of catastrophic impairment in Ontario‟s automobile
insurance system.
OSOT recognizes and applauds the following significant directions of the Panel‟s
recommendations;

The development of an interim catastrophic impairment status which will enable
insured individuals with serious injuries to access the rehabilitation services they
require to achieve their functional potential which may result in a final impairment level
that is less than catastrophic.

The recognition of the long-term developmental implications of traumatic brain injuries
in the paediatric population and development of more age specific definitions of CAT
impairment for this population.

The recognition of the impact of having significant mobility concerns has on function.

The proposed use of assessment systems with acceptable validity, reliability and
predictive ability when determining presence of catastrophic impairment. We
acknowledge the new tools recommended by the Panel and support their testing and
validation for the proposed uses.
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The Society offers the following comments and recommendations relating to
recommendations of the Expert Panel…..
Section 4 – Catastrophic Impairment Definitions
“In summary, the Panel agreed that a catastrophic impairment is “an extremely serious
impairment or combination of impairments that is expected to be permanent and which
severely impacts an individual's ability to function independently. It was the opinion of
the Panel that catastrophic impairment is not a medical entity; rather, it is a legal entity
which defines a point along the medical spectrum of impairment severity.” (Section 4,
page 13)
OSOT response:
We wish to emphasize that the Panel‟s definition states that a catastrophic impairment
severely impacts the individual‟s ability to function independently. However, the Panel‟s
recommendations continue to propose criteria for determination of catastrophic (CAT)
impairment that focus on „impairments‟ instead of criteria that focus on determining whether
someone‟s ability to function independently is severely impacted. This is inconsistent with
other definitions within the SABS which determine eligibility to benefits based on function,
e.g., „substantial inability to engage in‟ for housekeeping, essential work demands (IRB) and
caregiving. The Panel acknowledges that impairment itself is not always predictive of function,
and ability to function is not always explained by impairment alone.
While it was the Expert Panel‟s opinion that catastrophic impairment is a legal entity, there
was no review of legal precedents relating to the definition of this impairment.
OSOT Recommendation:
1.
Criteria for determination of catastrophic impairment should reflect the Panel‟s
definition of catastrophic impairment:
a. Impairment is serious and considered permanent, and
b. The impairment or collection of impairments severely impacts the person‟s
ability to function independently.
2.
Given that CAT determination permits increased funding for the injured claimant, it
is recommended that the threshold for catastrophic impairment should factor in the
duration and cost of treating the condition and its functional implications. The Panel
applied this same rationale, i.e. cost of treatment, when they proposed the concept
of “interim catastrophic designation.”
3.
A review of legal precedents should inform decision-making relating to the
definition and criteria for determination of catastrophic impairment.
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Section 4.1 Definitions – Paediatric definitions
“Given the complexity of the issues, and the time constraints, the Panel determined that it
was unable to adequately address adaptations to definitions 2 (e) (section 4.1.5) and 2 (f)
(section 4.1.6) for the paediatric population. The Panel recognizes that adapting these
definitions to the paediatric population is a priority and recommends that an Expert
Paediatric Working Group be convened to address this issue as soon as possible. In the
interim, the Panel recommends that the determination of catastrophic impairment for
individuals younger than 18 years of age who sustain an impairment that is not covered by
definitions 2 (a), 2 (b), 2 (c) or 3 be done by seeking the closest analogy using definitions 2
(e) and 2 (f) as well as the other adult definitions.” Section 4.1.1, Page 13
OSOT Response:
OSOT supports the panel‟s reasoning and recommendation relating to the adaptation of the
CAT definition to the pediatric population and further supports the need for a Paediatric
Working Group to address the definitions for this population.
OSOT Recommendations:
4.
OSOT recommends that an occupational therapist, experienced in working with the
paediatric population, considered by peers to be an expert in assessing and treating
functional impairments in children, and who possesses familiarity with the
developmental implications of catastrophic injury be included on this Expert
Paediatric Working Group.
Section 4.1.2 Interim Catastrophic Impairment Status
“The Panel recommended that an interim catastrophic impairment status be created for
patients whose impairments specifically meet or exceed the criteria outlined under
definition 2(d), 2(e) (Traumatic Brain Injury) ….. The Panel also believes that a
designation of interim catastrophic impairment status is necessary to balance access to
higher level of funding necessary for early rehabilitation with the need to minimize the
risk of patients being permanently designated as catastrophically impaired when there
is a reasonable chance that they will cease to be catastrophically impaired.” Section
4.1.2, page 13.
OSOT response:
OSOT supports the recommendation for an interim catastrophic impairment status for the
reasons outlined by the Panel. However, we have some concerns that the thresholds to
achieve an interim catastrophic status, as outlined by the Panel (Section 4.1.6.1), will restrict
the very individuals the interim status would serve to protect. Accordingly, OSOT positions
that further attention is required to achieve fair and equitable criteria for this status and to
review the timeframes for inclusion into the interim status. Furthermore, OSOT is concerned
that extending the interim status to only those individuals who sustain traumatic brain injuries
or major physical impairments excludes other categories of injury that may be equally well
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served with immediate access to the financial benefits of catastrophic designation, such as
those with spinal cord injury.
Section 4.1.3
2(a) – Paraplegia/Tetraplegia:
2. For the purposes of this Regulation, a catastrophic, impairment caused by an accident is,
2(a) paraplegia or tetraplegia that meets the following criteria i and ii, and either iii or iv:
i.
The Insured Person is currently participating in, or has completed a period of, inpatient spinal cord injury rehabilitation in a public rehabilitation hospital;
Section 4.1.3 2(a), page 14
OSOT response:
OSOT cannot support the inclusion of criteria 2 (a) (i) for individuals who have sustained a
spinal cord injury. The specific requirement that these individuals must participate in inpatient spinal cord injury rehabilitation in a public rehabilitation hospital is problematic for the
following reasons;

Inclusion of participation in an in-patient rehab program specific to spinal cord injury is
geographically discriminating as specialized spinal cord injury rehabilitation programs are
not accessible in all regions of the province, particularly in rural Ontario.

Wait lists for access to specialized SCI beds may limit a client‟s access to early
rehabilitation. Faced with wait lists, individuals may be discharged home, to another
type of general rehabilitation program, to long-term care or temporary accommodation.

Individuals with dual diagnoses may be ineligible for admission to specialized SCI rehab
units and may be admitted to services to deal with their secondary diagnosis, e.g. mental
health or orthopedic issues.

While provincial waitlist data for access to spinal cord injury rehabilitation centres would
indicate that approx 85% of persons with spinal cord injury do access in-patient
rehabilitation services, there remains 15% of injuries that may not. In these cases and
in others where claimants make choices to return home or to their community,
individuals may access community based rehabilitation services with expertise in spinal
cord injury. These community based services, which are typically not publicly funded,
have been found to be effective in returning individuals back to home, community and
the workplace. Success in rehab may be due in part to the community team‟s ability to
assist their client and their families who are frequently significantly involved, in their own
environment and with their own support networks. Notwithstanding the potential for
successful rehabilitation outcomes in these programs, which are not in-patient spinal
cord rehabilitation programs, individuals who participate actively in rehabilitation in the
community would not meet the criteria for catastrophic designation.

Individuals may have such significant limitations that they are not deemed rehabilitation
candidates (for example a ventilator dependent individual or someone who has also
sustained a TBI). Such individuals who are clearly catastrophically impaired would not
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meet the criteria for designation.

There may be circumstances in which an individual has been injured in the USA or out of
Canada where there may not be a public hospital system similar to that of Ontario. This
situation should not de facto cause the person to lose access to increased benefits
resulting from CAT designation. In fact, an individual‟s financial need may increase to
ensure payment for out-of-country services which would normally be covered by OHIP.

This criteria has the potential to be both inappropriate and discriminatory when applied
to claimants who do not meet the criteria as a result of limitations of the publicly funded
health care system in their community. The potential exclusion of clients and the
subsequent financial limitations to their ability to seek appropriate treatment when
publicy funded in-patient spinal cord injury rehabilitation services are not regionally
accessible challenges principles of fairness and equity.

Current health system trends would suggest increasing attention to minimization of
hospital stays and promotion of community based health services and rehabilitation. It
would be prudent to ensure that criteria for the designation of CAT impairment are not
dependent on health system service delivery models that may evolve. It is not
unreasonable to vision a future in which some SCI patients go home after acute care to
participate in either out-patient or community based programming , which may be either
publicly or privately funded.

OSOT is not aware of specific in-patient spinal cord injury rehabilitation services for
children in Ontario. We assert that it is important that the criteria for CAT determination
be applicable fairly and equitably for both adults and children.
These examples give evidence of situations in which a seriously injured individual would not
meet the criteria for designation.
Section 4.1.3 2(a) iv – Paraplegia/Tetraplegia
iv. The permanent ASIA Grade is or will be D provided that the insured has a permanent
inability to walk independently as defined by scores 0–3 on the Spinal Cord
Independence Measure item 12 (indoor mobility, ability to walk <10 m) (Catz A,
Itzkovich M, Tesio L, et al. A multicenter international study on the spinal cord
independence measure, version III: Rasch psychometric validation. Spinal Cord
2007; 45: 275–91) and/or requires urological surgical diversion, an implanted
device, or intermittent or constant catheterization in order to manage the residual
neuro-urological impairment. Section 4.1.3, 2(a) iv., page 14.
OSOT response:
The Society challenges the application of the ASIA Grade D as a criteria for catastrophic
impairment for individuals who suffer incomplete spinal cord injuries for the following reasons;

People who sustain an incomplete SCI may suffer severe neurological pain, spasms,
bowel and bladder deficits, erectile dysfunction, impaired mobility, and inability to
perform their personal care and activities and daily living. These factors indicate severe
impact on the person‟s ability to function independently. To determine access to
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catastrophic benefits based on 10 metres of indoor walking does not address the
wholistic implications this diagnosis can have on an individual.

A person with an incomplete spinal cord injury who requires mobility aids is not only
limited in their ambulation but also in their capacity to manage other ADL skills as a
result of their reliance on a mobility aid. Though an individual may be able to walk 10
metres, they may require significant home modifications and typically use several
mobility aids depending upon the environment in which they need to function (e.g.,
crutches/canes, walkers, and wheelchair over longer distances), age, physical status
and functional abilities. Their ability to sustain mobility with aids often requires intense
and ongoing rehabilitation. This group should not be limited in their access to
rehabilitation. Early rehabilitation and access to funding to support home/workplace
modification is important but so too is access to rehabilitation over their lifetime, as the
degree of independent or functional mobility tends to deteriorate with aging.

The Spinal Cord Independent Measure (SCIM) was developed to improve upon the
Functional Independence Measure (FIM) which was not sensitive to the SCI population.
The SCIM was developed for hospital use in an acute care setting to track basic
function before and after an in-patient rehabilitation program. It was designed for
research and found to be a consistent, reliable, and valid scale for use in a clinical
setting, not in a home or community setting. The SCIM is limited in its scope of
assessment. We position it is not a reliable measure for home/community mobility.

OSOT is not aware that research has validated the use of one component of the SCIM
tool in isolation of other components as a prediction of outcome. Accordingly we are
concerned about the splitting of one item (#12) from the SCIM measure from the subscale of “mobility”. The evidence or rationale for this decision is not apparent in the
Panel‟s report. We question why there is not a recommendation to use the tool in its
entirety. The rationale for excluding the impact that spinal cord injury has on self-care,
respiration and sphincter management in this measure is also unclear.

Catastrophic definitions using the ASIA scale will not address the needs of persons
suffering from central cord syndrome, cauda equina or Brown Sequard‟s syndrome who
experience upper limb limitations to a more significant degree than in lower limbs.
They may be able to walk 10 metres but be severely limited in their functional ability to
manage self care, balance, community mobility, etc.
OSOT Recommendation:
5.
OSOT recommends that all clients with complete and incomplete spinal cord injury
be defined with catastrophic impairment. This provides access to increased levels of
medical and rehabilitation services that are typically required by this seriously
injured population for both early medical and rehabilitation management and those
ongoing needs experienced over the lifespan.
Section 4.1.6 2(d) - Traumatic Brain Injury in Adults (18 years of age or older):
OSOT recognizes that two different approaches have been recommended for the
determination of catastrophic impairment for persons with traumatic brain injury (TBI) to
accommodate both the possibility that the government will accept the Panel‟s recommendation
that an interim catastrophic status be approved and the possibility that it not be approved.
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The Society assertively supports the recommendation for the designation of a interim
catastrophic designation.
Sections 4.1.6.1 2 (d) – TBI if Interim Catastrophic Impairment Status is Approved.
2. For the purposes of this Regulation, a catastrophic impairment caused by an accident is,
i.
An Insured is granted an interim catastrophic impairment status when accepted for
admission to a program of inpatient neurological rehabilitation at a recognized
neurological rehabilitation center (List of facilities to be published in a
Superintendent Guideline).
ii.
Catastrophic impairment, based upon an evaluation that has been in accordance
with published guidelines for a structured GOS-E assessment (Jennett, B. and Bond,
M., Assessment of Outcome After Severe Brain Damage, Lancet i:480, 1975)49, to
be: a) Vegetative (VS) after 3 months or b) Severe Disability Upper (SD+) or
Severe Disability Lower (SD -) after 6 months, or Moderate Disability Lower (MD-)
after one year due to documented brain impairment, provided that the
determination has been preceded by a period of inpatient neurological rehabilitation
in a recognized rehabilitation center (List of facilities to be published in a
Superintendent Guideline) Section 4.1.6.1, page 17,
OSOT response:
Reviewers have found the recommendation of Section 4.1.6.1 (ii.) unclear. Mulitiple readers
identified varying interpretations of this criterion. It is unclear whether it is an expectation
that “the determination has been preceded by a period of in-patient neurological rehabilitation
in a recognized rehabilitation centre” applies to all claimants regardless of their level according
to the GOS-E or whether this requirement applies only to those with Moderate Disability Lower
(MD-). We trust this is largely a documentation clarification as the Panel‟s rationale on page
18 of the Report identifies that “….any finding other than Vegetative must be associated with a
preceding period of in-patient neurological rehabilitation.”
It is OSOT‟s position that inclusion of the requirement for participation in an in-patient
neurological rehabilitation program as a component of the criteria for determination of CAT
impairment of adults with TBI is problematic. Occupational therapists report that an
expectation that individuals will access in-patient neuro rehab services is not consistent with
typical practice in Ontario. We suggest this requirement be removed for the following
reasons:

This criteria overlooks patients with multiple injuries from an accident that are often
streamed into other types of rehabilitation programs to address other injuries (e.g.,
complex orthopedic)1

This criteria excludes those persons whose TBI may not be addressed while an
inpatient and may not even be diagnosed until post-discharge.

One journey of care that individuals with TBI may experience starts with stabilization of
their injuries in an acute hospital setting with subsequent discharge home while they
may be on a wait list for an in-patient neuro-rehab facility. Once home, the person is
usually linked with a community therapy program and a care team is established.
When a rehab bed eventually becomes available, the client, feeling adequately
1
Colantonio, A., LaPorte, A., Croxford, R., & Coyte, P. (2005). Who receives in-patient rehabilitation after traumatic
brain injury? A population-based study. Archives of Physical Medicine and Rehabilitation, 86(10), e21-22.
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supported in their community, may decline the in-patient experience. We question
why emphasis should be placed on more expensive institutionally based services if care
needs can adequately be supported in the individual‟s community. Further, we position
that individuals who participate in active community based neuro rehabilitation should
not be deprived of opportunity for interim catastrophic impairment designation.

The literature supports that it is more effective to complete rehabilitation in the
patient‟s own environment whenever possible, given the frequent difficulty in
transferring and applying skills learned in the institutional environment to the
community environment.

OSOT asserts that if the rationale for requiring in-patient rehabilitation services was to
assure access to neuro rehabilitation expertise, this argument is difficult to defend in
light of the breadth of service and experience for TBI that can be accessed in many
communities. We do not agree with the Panel‟s assertion that treatment in the
community as opposed to in an in-patient program does not provide „expert rehab‟.

There are instances where people with TBI are discharged home prior to any
rehabilitation to be managed with supervision or to convalesce, particularly when there
is no apparent need for neurosurgical intervention. This management approach does
not, in and of itself, reflect the severity of the injury.

The requirement for participation in an in-patient neuro rehabilitation program will
exclude clients with severe TBI who are never „rehab-ready‟, do not meet the eligibility
criteria for admission into an inpatient rehabilitation program, but who have significant
medical and care needs and may have a need for attendant care over their lifetime.
These individuals may go from the acute facility to a Long Term Care Facility, or may
receive rehabilitation from community based fee for service professionals and improve
their functional status sufficiently for family members to manage them at home or to
enable them to be transferred to a facility which requires a lower level of care

While occupational therapists would position that the ideal rehabilitation pathway for
persons with TBI may include specialized neuro rehabilitation services in a
rehabilitation centre, we position that in light of access to care issues, wait lists and
geographic discrepancy with respect to local services, participation in a general
rehabilitation program may be sufficient demonstration of the requirement for
participation in in-patient rehabilitation.

Currently there are only 109 adult TBI beds (Ministry of Health and Long-Term Care
Report of the Trauma Expert Panel, 2006). We express concern that a requirement
that any person with a TBI that wishes to be eligible for CAT impairment designation
must participate in a specialized rehab program will place additional pressure on this
limited number of publicly funded beds.

There are other reasons why individuals injured with TBI choose NOT to receive
therapy in an in-patient facility but stay in their local community such as ; cultural and
religious reasons, distance from other family members, to meet unique needs such as
an adult with developmental delay who is better in their familiar environment, an adult
with prior psychiatric and/or behavioural problems, or adults with complex care needs
who is better served in a familiar environment.
Our reviewer‟s questioned the standardization of the GOS-E in relation to the time of
administration. It is questioned whether an assessment at 3 months or 6 months to
determine an interim CAT designation could be made sooner so as to enable a seriously
injured individual to begin to access treatment, equipment, medications, supports, etc. as
soon as possible to support their rehabilitation and recovery.
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OSOT Recommendations
6.
In the spirit of assuring fairness so that individuals who are the most seriously
injured in motor vehicle accidents receive appropriate treatment, OSOT
recommends that the criteria 2 (d) (for TBI in adults if interim CAT impairment
approved) be amended to require;
i)
that an individual be admitted to a hospital and have positive findings on CT,
MRI or PET scan or any other braining imaging technology indicating
intercranial pathology that is the result of the accident.
ii) Catastrophic impairment, based upon an evaluation that has been in accordance
with published guidelines for a structured GOS-E assessment (Jennett, B.
and Bond, M., Assessment of Outcome After Severe Brain Damage, Lancet
49
i:480, 1975) , to be:
a.) Vegetative (VS) after 3 months or
b.) Severe Disability Upper (SD+) or Severe Disability Lower (SD -) after 6
months, or Moderate Disability Lower (MD-) after one year due to
documented brain impairment.
The Panel has recommended that a child admitted to a special trauma or rehabilitation centre.
We position that an adult with a TBI admitted to an in-patient neuro rehab program should
automatically be deemed CAT or at very least interim CAT.
Section 4.1.6.2 2(d) If Interim Catastrophic Impairment Status is not Approved
2d: Traumatic Brain Injury in Adults (18 years of age or older):
“The GOS-E has strong psychometric properties and it is particularly reliable when a
structured interview, standard scoring algorithm and a quality control system are used to
The impairment is deemed to be catastrophic, when determined in accordance with
monitor itsguidelines
administration
and scoring”
(Appendix)
published
for a structured
GOS-E
assessment (Jennett, B. and Bond, M.,
Assessment of Outcome After Severe Brain Damage, Lancet i:480, 1975)49, is:
“…the panel recognized that this finding, made in isolation, might be problematic and
i.
Vegetative
(VS)
after
3 months,
or
consequently
stipulated
that
any
finding other
than Vegetative must be associated with a
ii.
Severe
Disability
Upper
(SD+)
or
Severe Disability
Lower (SD-)these
after features
6 months,
preceding period of inpatient neurological rehabilitation.
In combination,
will
or
increase the sensitivity and specificity of the determination, and reduce any variability
iii.
Moderate Disability Lower (MD-) after 1 year, provided that the determination
which might arise from reliance upon the GOS-E definitions, when discriminating Moderate
has been preceded by a period of inpatient neurological rehabilitation in a
(Lower) from
lesser rehabilitation
levels of impairment.
requirement
of a preceding
period of
recognized
center (ListThe
of facilities
to be published
in a
inpatient rehabilitation
also
ensures
that
the
patient
has
been
exposed
to
and
has
engaged
Superintendent Guideline)
in an appropriate
level
Section
4.1.6.2, page
17of expert rehabilitation before a determination is made.12, section
2).” Section 4.1.6 Rationale for revisions of 2 (d), page 18.
OSOT response:

As above, the Society positions that the qualifier that all but those deemed Vegetative
as per the GOS-E have participated in an in-patient neuro-rehabilitation program, is not
appropriate for the reasons noted above.
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
OSOT submits that persons in the category of Moderate Disability Upper (MD+) suffer
from:
o
o
o
Reduced work capacity
Able to participate in < half their pre-injury leisure/social activities
Family/Friends disruptions are at least weekly and intolerable
This too describes an individual with significant dysfunction as it relates to his/her brain
injury. OSOT recommends that, rather than using an in-patient stay as a secondary
criteria, the person should undergo assessment which may include neuropsychological
assessment in combination with cognitive/functional assessment, which must include
client effort and symptom validity measures, to ensure that the person meets this
criteria.

It is our position that expert, timely and coordinated rehabilitation in the community,
including multi-disciplinary services, can be found in many communities across the
province. There is not, in our opinion, a need to restrict access to rehabilitation to inpatient services for the purposes of accessing specialized care.

We challenge the premise that participation in an in-patient rehabilitation program is
the best predictor of future function, or future costs or duration of treatment.
OSOT Recommendations:
7.
In the spirit of assuring fairness so that individuals who are the most seriously
injured in motor vehicle accidents receive appropriate treatment, OSOT
recommends that the criteria 2 (d) (for TBI in adults if interim CAT Impairment
status not approved) be amended to require;
a. Catastrophic impairment, based upon an evaluation that has been in accordance
with published guidelines for a structured GOS-E assessment (Jennett, B. and
Bond, M., Assessment of Outcome After Severe Brain Damage, Lancet i:480,
1975
)49
, to be:
a.) Vegetative (VS) after 3 months or
b.) Severe Disability Upper (SD+) or Severe Disability Lower (SD -) after 6
months, Moderate Disability Lower (MD-) and Moderate Disability
Upper (MD+) assessment which may include neuropsychological
assessment in combination with cognitive/functional assessment, which
must include client effort and symptom validity measures
8.
The Panel has recommended that a child admitted to a special trauma or
rehabilitation centre. We position that an adult with a TBI admitted to an inpatient neuro-rehab program should automatically be deemed CAT or at very least
interim CAT.
9.
Include MD-upper as the cut-off level of disability identified by the GOS-E for the
purposes of determining CAT impairment.
10.
OSOT recommends that, rather than using an in-patient stay as a secondary criteria
for MD - and potentially MD+, the person should undergo assessment which may
include neuropsychological assessment in combination with cognitive/functional
assessment, which must include client effort and symptom validity measures, to
ensure that the person meets this criteria.
10
Section 4.1.7 2 (e) – Oher Physical Impairments
The Panel explained, “Moreover, we found no literature supporting the use of a 55% WPI
threshold as a cut-point for catastrophic impairment status. However, we note that 55%
WPI is the score given to paraplegia, which the Panel agreed was a reasonable exemplar of
the catastrophically impaired accident victim.” Section 4.1.7, Rationale for revisions of
2(e), page 19.
OSOT response:
OSOT challenges the position that 55% WPI, which is a score given to paraplegia, should set
the bar for all catastrophic determinations. This “bar” was set in 1996 with the knowledge
that at the time $100,000 (plus assessment costs) was available to all victims for medical and
rehabilitation benefits and the limit for attendant care benefits was $72,000. The recognition
that individuals with catastrophic injuries would require in excess of these funding limits
resulted in access to $1 million. Fifteen years later, benefits have now been reduced and most
related costs have increased; it would be reasonable to decrease the CAT threshold to capture
the increased number of individuals who will require more than the current $50,000 medical
rehabilitation benefit limit.
“The Expert Panel did not find that combining physical and mental/behavioural conditions
can be achieved in a valid and reliable way with the currently available methods of
impairment cross-rating. Moreover, the Expert Panel did not find sufficient evidence that
combined impairment ratings are more clinically meaningful than using separate criteria.
While 55% physical impairment establishes paraplegia as a prime example of catastrophic
impairment, we did not find evidence for an equivalent threshold when physical and
mental/behavioral impairments are combined. The Panel had difficulty understanding how
combinations of physical impairments and psychological conditions that independently do
not meet the criteria outlined in the revised version of 2(e) and 2(f) could be equated to a
severe injury to the brain or, spinal cord or to blindness. Further investigation of this area
is needed. Specifically defining a clinically comparable combined psycho-physical whole
person impairment threshold that corresponds to the currently accepted physical threshold
is needed. Therefore, until further scientific evidence is gained, we recommend that
separate criteria and methods of evaluation be used for the determination of catastrophic
impairment and that physical and psychiatric impairments not be combined for the purpose
of catastrophic determination.” Executive Summary, page 4.
OSOT response:
The literature consistently describes a link between psychological distress and chronic physical
disability and/or chronic pain2. According to Turner and Noh (1988), the disabled are at
dramatically elevated risk for depressive symptoms and that this high level of depression
characterizes both men and women of all ages. Longitudinal analyses show eventful stress,
chronic strain, mastery, and social support to be significant determinants of depression in this
2
Physical Disability and Depression: A Longitudinal Analysis, Turner and Noh, Journal of health and social behaviour,
1988, Vol 29, March 23-37
11
population. Only the effects of mastery and social support, however, are clearly observable
within all age groups. Additionally, there has been legal precedent set in Ontario with respect
to combining physical and psychological scores. Bambers3, for example, provided an update
on catastrophic impairment and a review of legal decisions (2009) that have challenged the
use of combining physical and psychological disabilities since Desbiens. 4 Bambers stated, “In
the meantime, insurers will have to consider the possibility that minor or modest psychological
impairments could render insureds catastrophically impaired when combined with physical
injuries which in and of themselves would be non-catastrophic. Insurers can seek some solace
in the fact that not all insureds that qualify as catastrophically impaired by combining physical
and psychological impairments, will require the increased benefits provided by the scheme”.
OSOT Recommendation:
11.
Until such time that evidence disproving catastrophic impairment for individuals
experiencing both physical and psychological disabilities is provided, OSOT
maintains the position that physical and psychological disabilities should be
combined. Guidance should be sought from legal precedent. Further study is
recommended.
Section 4.1.7 2 (e) – Other Physical Impairments (not covered by 2(a), 2 (b), 2 (c)
or 2 (d))
Proposed definition:
2.
the purposes
of this Regulation,
a catastrophic
impairment
by an accident
iii.For
Definition
2(e), including
subsections
I and II, cannot
be used caused
for a determination
of is,
catastrophic impairment until two years after the accident, unless at least three months
2after
(e): the
A physical
impairment
combination
of physical
impairments
in accordance
accident,
there is a or
traumatic
physical
impairment
rating of that,
at least
55% WPI and
with
the
American
Medical
Association’s
Guides
to
the
Evaluation
of
Permanent
Impairment,
there is no reasonable expectation of improvement to less than 55% WPI.
4th edition 1993, (GEPI-4), results in a physical impairment rating of 55 per cent whole
person
Sectionimpairment
4.1.7, page(WPI).
18.
i.The
Unless
covered
by no
specific
rating
guidelinesthe
within
relevant
of Chapters
3-13
panel
“…found
literature
supporting
use of
a 55%Sections
WPI threshold
as a cut-point
of
all impairments
relatable
non-psychiatric
and is
syndromes
forGEPI-4,
catastrophic
impairment
status. to
However,
we note symptoms
that 55% WPI
the score (e.g.
given to
functional
somatic
chronic
pain
syndromes,
chronic fatigue
syndromes,
paraplegia,
which syndromes,
the Panel agreed
was
a reasonable
exemplar
of the catastrophically
fibromyalgia
Syndrome,
etc.)
ariseliterature
from thereview
accident
are to be
understood
to have
impaired accident
victim.
Thethat
Panel’s
suggests
that
the reliability
of the
been
into theatweighting
of the GEPI-4
physical
impairment
set out in
AMA incorporated
Guides is moderate
best in patients
with either
low back
pain or ratings
major trauma
Chapters
3–
13.
(Appendix
12,
section 1).” Section 4.1.7, Rationale for Revision of 2 (e), page 19.
ii. With the exception of traumatic brain injury impairments, mental and/or behavioural
impairments are excluded from the rating of physical impairments.
OSOT response:

We note little to no evidence in the report that outlines the Panel‟s methodology for
continuing with a 55% threshold particularly in contrast to their diligence in other
areas. For example, how was this literature review conducted?
3
Rita Bambers (2009). An update on catastrophic impairment. Retrieved May 11, 2011 from
http://www.duttonbrock.com/dutton/news/mm/1_161.pdf
4
[2004] O.J. No. 4735 (S.C.J.)
12

Given their consensus that the definition of „catastrophic impairment status‟ is a legal
entity, it is unclear why relevant legal decisions and cases were not reviewed or legal
consultation sought.

It is unclear why Chapter 15 on Pain from the AMA Guides 4 th Edition has been
excluded given the Panel‟s recommendation that all pain disorders should be included
under this criteria.

The Panel identifies the need for research to determine how to most appropriately rate
Whole Person Impairment scores for various psychophysical combinations but does not
recommend a working group to address this area nor defer to legal consultation to
inform the Panel of relevant case decisions

There is evidence in the literature that suggests a strong correlation between physical
disability and psychological sequelae In the absence of evidence indicating otherwise,
guidance should be sought from legal precedence and further study recommended.
Section 4.1.7
2 (e) If Interim Catastrophic Impairment Status is Approved
2 (e)
iv. Interim catastrophic impairment status is deemed to apply to any patient whose
traumatic physical impairment rating is at least 55% WPI, when that determination is made
at least three months after the accident date.
v. Interim catastrophic impairment status ceases to exist as soon as a final determination
has been made, in accordance with Criterion III guidelines, and in any event no later than
two years after onset. Section 4.1.7, page 19.
OSOT recommendations:
12.
OSOT supports the need for the interim determination to ensure access to early
rehabilitation which promotes maximal medical recovery for persons with traumatic
physical impairments.
Section 4.1.8
2 (f) – Psychiatric Impairment
2. For the purposes of this Regulation, a catastrophic impairment caused by an accident is,
2(f) psychiatric impairment that meets the following criteria:
i.
The post-traumatic psychiatric impairment(s) must arise as a direct result of one or
more of the following disorders, when diagnosed in accordance with DSM IV TR
criteria: (a) Major Depressive Disorder, (b) Post Traumatic Stress Disorder, (c) a
Psychotic Disorder, or (d) such other disorder(s) as may be published within a
Superintendent Guideline. Section 4.1.8, page 20.
OSOT response:
13
OSOT submits that the list of diagnoses contained in 2 (f) i is not inclusive of all the diagnosis
that should be considered catastrophic. For example, conversion disorder can produce
significant disability. Further, OTs are uncertain how or if this particular definition in (i) would
apply to children 18 years or younger.
OSOT recommendations:
13.
ii.
An expert panel should be struck to investigate a 2(f) determination with in-depth
study regarding the psychiatric conditions typically arising from trauma.
Impairments due to pain are excluded other than with respect to the extent to which
they prolong or contribute to the duration or severity of the psychiatric disorders
which may be considered under Criterion (i)
OSOT response:
Chronic pain literature is clear on the debilitating effects that pain can have on function. 5
OSOT submits that conditions such as chronic pain disorder can be the result of injury(ies)
sustained in a motor vehicle accident and, based on our members‟ collective experience, this
disorder can result in significant client dysfunction and family upheaval.
OSOT recommendation:
14.
OSOT recommends that chronic pain disorder combined with a GAF score of 50 or
under be considered catastrophic.
iii.
Any impairment or impairments arising from traumatic brain injury must be
evaluated using Section 2(d) or 2(e) rather than this Section.
iv.
Severe impairment(s) are consistent with a Global Assessment of Function (GAF)
score of 40 or less, after exclusion of all physical and environmental limitations.
OSOT response:
OSOT submits that a GAF assessment itself addresses a “range” in scoring rather than a
specific score, and there is wide variability from assessor to assessor.6 As well, the GAF is
meant to provide a “snap-shot” of the person at one time as opposed to a long term forecast
of function. Finally, the GAF test result can vary dependent on what sphere of function is
being examined.
5
The Effects of Depression and Chronic Pain on Psychosocial and Physical Functioning,Holzberg, Amy D. Ph.D.;
Robinson, Michael E. Ph.D.; Geisser, Michael E. Ph.D.; Gremillion, Henry A. D.D.S.,Clinical Journal of Pain, June 1996,
Vol 12, Issue 2, 118 - 125
6
Psychiatr Serv 56:434-438, April 2005, © 2005 American Psychiatric Association
Special Section on the GAF: Reliability of Global Assessment of Functioning Ratings Made by Clinical Psychiatric Staff,
Per Söderberg, M.Sc., Stefan Tungström, M.Sc. and Bengt Åke Armelius, Ph.D.
14
For the reasons above we urge caution in establishing a GAF score criteria that is too low (40
or less). It was noted at the public consultation that the State of California has found that a
GAF of 39 – 50 is consistent with a 55% WPI rating.
OSOT recommendation:
15.
v.
Should the government concur with the panel‟s findings about relying on the GAF
Assessment, OSOT submits that the GAF cut-off should be 50 rather than 40. A
GAF score of 50 describes “Serious symptoms (e.g., suicidal ideation, severe
obsessional rituals, frequent shoplifting) OR any serious impairment in social,
occupational, or school functioning (e.g., no friends, unable to keep a job).” This
would indicate a need for a substantive level and duration of treatment.
For the purposes of determining whether the impairment is sufficiently severe as to
be consistent to Criterion (iv) - a GAF score of 40 or less - at minimum there must
be demonstrable and persuasive evidence that the impairment(s) very seriously
compromise independence and psychosocial functioning, such that the Insured
Person clearly requires substantial mental health care and support services. In
determining the demonstrability and persuasiveness of the evidence, the following
generally recognized indicia are relevant:
a. Institutionalization;
b. Repeated hospitalizations, where the goal and duration are directly related to the
provision of treatment of severe psychiatric impairment;
c. Appropriate interventions and/or psychopharmacological medications such as:
ECT, mood stabilizer medication, neuroleptic medications and/or such other
medications that are primarily indicated for the treatment of severe psychiatric
disorders;
d. Determination of loss of competence to manage finances and property, or
Treatment Decisions, or for the care of dependents;
e. Monitoring through scheduled in-person psychiatric follow-up reviews at a
frequency equivalent to at least once per month.
f. Regular and frequent supervision and direction by community-based mental
health services, using community funded mental health professionals to ensure
proper hygiene, nutrition, compliance with prescribed medication and/or other forms
of psychiatric therapeutic interventions, and safety for self or others.
Section 4.1.8, page 21
OSOT response:
OSOT submits that, in the practical world, admission to hospital or institutionalization occurs
rarely for those persons with mental and behavioural disturbances given the social stigma of
mental illness. Furthermore, the decision to admit or not to admit a person to an institution or
mental health hospital is a multi-factorial one which includes the person‟s support network
including treating psychiatrist and family members. Given the variability of rationale
surrounding this decision, admission should not influence the decision around catastrophic
impairment designation in either direction.
15
With respect to accessing a psychiatrist in Ontario or a mental health bed, there is a known
shortage of this specialty across the province, but in particular in northern Ontario. Reference:
http://www.bipolarworld.net/Bipolar%20Disorder/Articles/art45.htm
Similarly, community-based mental health services, again, are not predictably accessible.
OSOT would assert that a CAT designation should not hinge on economic factors nor the
availability of community-based, pubically-funded services.
Section (v) lists six indicia deemed relevant but does not reference how many must be
evidenced or met prior to assigning a CAT designation. We believe this leaves this section
open to interpretation and therefore, limited in its useful application.
Section 4.1.10 3 – Traumatic Brain Injury in Children
Paediatric Traumatic Brain Injury (prior to age 18)
“i. A child who sustains a traumatic brain injury is (automatically) deemed to have
sustained a catastrophic impairment automatically provided that either one of the
following criteria (a or b) is met on the basis of traumatic brain injury sustained in the
accident in question:
a. In-patient admission to a Level I trauma centre with positive findings on CT/MRI scan
indicating intracranial pathology that is the result of the accident, including but not
limited to intracranial contusions or haemorrhages, diffuse axonal injury, cerebral
edema, midline shift, or pneumocephaly; or
b) In-patient admission to a publically funded rehabilitation facility (i.e. an Ontario
Association of Children’s Rehabilitation Facility or equivalent) for a program of brain
injury rehabilitation.”
Section 4.1.10, 3, page 22.
Paediatric catastrophic impairment on the basis of traumatic brain injury is any one of the
following criteria:
ii. At any time after the first 3 months, the child’s level of neurological function does not
exceed the KOSCHI Category of Vegetative (Crouchman M et al., A practical outcome scale
for paediatric head injury. Archives of Disease in Childhood
18
2001; 84:1204) : The child is breathing spontaneously and may have sleep/wake cycles.
He may have non-purposeful or reflex movements of limbs or eyes. There is no evidence of
ability to communicate verbally or non-verbally or to respond to commands.
iii. At any time after the first 6 months, the child’s level of function does not exceed the
KOSCHI Category of Severe (Crouchman M et al., A practical outcome scale for
18
paediatric head injury. Archives of Disease in Childhood. 2001; 84:1204) : (1) The
child is at least intermittently able to move part of the body/eyes to command or
16
make purposeful spontaneous movements; for example, a confused child pulling at
nasogastric tube, lashing out at caregivers, or rolling over in bed. (2) May be fully
conscious and able to communicate but not yet able to carry out any self-care activities
such as feeding. (3) Severe Impairment implies a continuing high level of dependency,
but the child can assist in daily activities; for example, can feed self or walk with
assistance or help to place items of clothing. (4) Such a child is fully conscious but may
still have a degree of post-traumatic amnesia.
b
iv. At any time after the first 9 months , the child’s level of function remains seriously
altered such that the child is for the most part not age appropriately independent and
requires supervision/actual help for physical, cognitive and/or behavioural impairments
for the majority of his/her waking day.
OSOT Response:

While the Society supports the recommendation that a child who sustains a traumatic
brain injury be considered for automatic CAT designation, we contest the requirement
for admission to a Level 1 trauma centre or publicly funded rehabilitation facility for a
brain injury rehabilitation program. The rationale has been interpreted in relation to
other categories but holds for the paediatric population as well. Access and systemic
capacity issues should not play a factor in the designation of a catastrophic
impairment.

It is noted that injured children may be seen in an emergency room but if stabilized
thereafter sent home only to experience problems impairing their function later. Early
brain imaging is critical to provide evidence of intracranial pathology that can be
attributed to the injuries sustained in the accident.

OSOT supports the recommendation for use of the KOSCHI Scale however, as the
Panel points out that the scientific evidence on the psychometric properties of the
KOSCHI are preliminary there is concern about implementing this tool prior to its
validation.

OSOT applauds the suggestion that more study is required into the use of the KOSCHI
and recommends that Occupational Therapy be part of this investigation.

As noted above with respect to adult assessment using the GOS-E, we query the
potential to assess children with the KOSCHI earlier, for example, at 1, 3 and 6
months. In light of the severity of impairment that they are measuring at these key
milestones post injury it can be anticipated that children classed as Vegetative or
Severe or have their function still seriously altered at 6 months will have significant
medical and rehabilitation needs that reasonably need access to a higher threshold of
funding.

It is important to ensure that the CAT criteria are developed by FSCO with appropriate
stakeholder input, and not liable to change based upon unrelated public health care
policies or funding. For e.g., if more inpatient rehabilitation beds become available,
and therefore the admission criteria are lowered to accept less severe patients, this
should not impact the CAT Definition. Alternatively, if there are funding cuts, or an
increase in referrals for any other reason, and hospitals can only accept the very most
severe, this should not affect the CAT Definition.
A case study demonstrates some of the concerns raised:
17
CASE #1
Katy M. was 4 years, 1 month old at the time of the accident on November 17, 2005.
Unfortunately she was run over by her mother when backing out her SUV from the garage
when Katy ran out the front door and behind her mother‟s car. It was felt that the ties of her
hat possibly choked her when she was run over. Glasgow Coma at the scene was 13 and
decreased to 10 in the ambulance on the way to the local hospital in North Bay. Two hours
later the GCS was 12/15. Katy remained in CCU for 3 days and then transferred to a regular
ward. She was discharged home on November 25, 2005. Injuries suffered as a result
included:
1) Bilateral pulmonary contusion and hemorrhage
2) Multiple lower right pulmonary laceration with pneumothorax
3) Suspicious intraparenchymal right chest tube
4) Multiple and full severe thickness laceration of the liver
5) Multiple small peripheral splenic lacerations
6) Extensive paracolic hematoma
7) Right colon contusion with extensive hematoma
8) Query fracture of head of right humerus
No radiological studies were done on the head at the time of the accident.
Subsequent CT Scans done six months post-accident due to behavioural changes indicated
minimal to moderate axonal damage.
Pre-accident, Katy was not attending pre-school and was at home with her grandmother. She
was slated to start Kindergarten next year. Her parents and grandparents (who live with the
family) stated that she was a very bright and sociable youngster who enjoyed looking at
books, was recognizing all her letters and numbers (1-10) as well as some simple words and
her name in print. She was riding a two-wheeler with training wheels and enjoyed drawing,
colouring, going to the park to play with peers and swimming.
Since the accident, Katy has been observed to be more emotional, to forget new learning
concepts, to have a weaker memory, to have less concentration and focus, some word finding
difficulty and to be more argumentative. She is now in grade 4. Katy‟s teacher reported that
Katy‟s reading, spelling and creative writing skills are below the class average and that she is
restless and needs a lot of assistance to initiate and complete tasks. Math is becoming more
problematic. Katy‟s parents discussed that they do extra homework daily to help Katy keep up
with her school studies. The teacher also shared that Katy has difficulty sitting for more than
20 minutes at a time and settling when coming in from recess. Socially, Katy gets easily
frustrated when she cannot produce work to her satisfaction; she cannot get her way and can
be verbally aggressive with peers and family. This is isolating her at recess and she is not
invited to birthday parties. Parents find that she has little insight into her behaviour and find
it difficult to reason with her.
Standardized testing by the school occupational therapist showed below average skills in
visual-motor integration, fine motor control, visual memory and visual sequential memory and
visual discrimination. Investigation into sensory processing showed difficulties with body
awareness in space, vestibular and proprioceptive seeking behaviour. She was recently given
a CAT designation.
OSOT Recommendations:
16.
In the spirit of assuring fairness so that children who are the most seriously injured
in motor vehicle accidents receive appropriate treatment, OSOT recommends that
the criteria 3 (i) (a) and (b) be replaced with:
18
a) Admission to a hospital and have positive findings on CT, MRI or PET scan or
any other braining imaging technology indicating intercranial pathology that
is the result of the accident.
17.
That if the KOSCHI is to be administered to a child after 6 months, the KOSCHI
should be administered by a physician with paediatric experience and a health
professional approved to complete an Attendant Care Assessment. Those
performing the Attendant Care Assessment must have clinical paediatric TBI and
paediatric attendant care assessment experience. All assessors should be also be
provided with all the relevant documentation available. The physician and/or
neuropsychologist input is needed in order to clarify the diagnosis, and that the
problems experienced are related to the accident. An Attendant Care Assessment
(which according to the SABS can only be done by an OT or Nurse) is needed in
order to obtain an objective measure of the attendant care required, including an
opinion on the number of hours during the waking day the child requires
supervision/actual help for physical, cognitive and/or behavioural impairments, and
an opinion on whether that care is considered normal parenting, or over and above
normal parenting, based upon the age of the client).
18.
OSOT supports further study of the psychometric properties of the KOSCHI. In this
regard, we propose that the GCS be used until such a time as the KOSCHI has been
shown to be a valid and reliable outcome measurement assessment tool.
19.
We recommend that children with subtle injuries that will become serious sources of
impairment over time will need access to a CAT attendant care/KOSHI or adult CAT
criteria assessment to be assessed for eligibility for CAT designation and should
have access to such assessment until the age of 21. OTs recognize that some
children will have a delayed manifestation sometimes spanning decades in the case
of infants whose impairments of cognition, emotion or behavioural regulation may
not fully express themselves until late teen years.
20.
OSOT recommends that children be assessed with the KOSCHI as early as is valid
so as to enable early identification of their status.
21.
That children with a significant pre-existing diagnosis at the time of the injury still
be considered catastrophic based on their presentation and clinical findings and not
be excluded from this group.
Summary of Recommendations
1.
Criteria for determination of catastrophic impairment should reflect the Panel‟s
definition of catastrophic impairment:
a) Impairment is serious and considered permanent, and
b) The impairment or collection of impairments severely impacts the person‟s
ability to function independently.
2.
Given that CAT determination permits increased funding for the injured claimant, it
is recommended that the threshold for catastrophic impairment should factor in the
duration and cost of treating the condition and its functional implications. The
Panel applied this same rationale, i.e. cost of treatment, when they proposed the
19
concept of “interim catastrophic designation.”
3.
A review of legal precedents should inform decision-making relating to the
definition and criteria for determination of catastrophic impairment.
4.
OSOT recommends that an occupational therapist, experienced in working with the
paediatric population, considered by peers to be an expert in assessing and
treating functional impairments in children, and who possesses familiarity with the
developmental implications of catastrophic injury be included on this Expert
Paediatric Working Group.
5.
OSOT recommends that all clients with complete and incomplete spinal cord injury
be defined with catastrophic impairment. This provides access to increased levels
of medical and rehabilitation services that are typically required by this seriously
injured population for both early medical and rehabilitation management and those
ongoing needs experienced over the lifespan.
6.
In the spirit of assuring fairness so that individuals who are the most seriously
injured in motor vehicle accidents receive appropriate treatment, OSOT
recommends that the criteria 2 (d) (for TBI in adults if interim CAT impairment
approved) be amended to require;
a)
that an individual be admitted to a hospital and have positive findings
on CT, MRI or PET scan or any other braining imaging technology indicating
intercranial pathology that is the result of the accident.
b)
Catastrophic impairment, based upon an evaluation that has been in
accordance with published guidelines for a structured GOS-E assessment
(Jennett, B. and Bond, M., Assessment of Outcome After Severe Brain Damage,
49
Lancet i:480, 1975) , to be:
a.) Vegetative (VS) after 3 months or
b.) Severe Disability Upper (SD+) or Severe Disability Lower (SD -) after 6
months, or Moderate Disability Lower (MD-) after one year due to
documented brain impairment.
7.
In the spirit of assuring fairness so that individuals who are the most seriously
injured in motor vehicle accidents receive appropriate treatment, OSOT
recommends that the criteria 2 (d) (for TBI in adults if interim CAT Impairment
status not approved) be amended to require;
a) Catastrophic impairment, based upon an evaluation that has been in accordance
with published guidelines for a structured GOS-E assessment (Jennett, B. and
Bond, M., Assessment of Outcome After Severe Brain Damage, Lancet i:480,
)49
1975 , to be:
i. Vegetative (VS) after 3 months or
ii. Severe Disability Upper (SD+) or Severe Disability Lower (SD -) after 6
months, Moderate Disability Lower (MD-) and Moderate Disability Upper
(MD+) assessment which may include neuropsychological assessment in
combination with cognitive/functional assessment, which must include
client effort and symptom validity measures.
8.
The Panel has recommended that a child admitted to a special trauma or
rehabilitation centre. We position that an adult with a TBI admitted to an in-
20
patient neuro-rehab program should automatically be deemed CAT or at very least
interim CAT.
9.
Include MD-upper as the cut-off level of disability identified by the GOS-E for the
purposes of determining CAT impairment.
10.
OSOT recommends that, rather than using an in-patient stay as a secondary
criteria for MD - and potentially MD+, the person should undergo assessment
which may include neuropsychological assessment in combination with
cognitive/functional
11.
Until such time that evidence disproving catastrophic impairment for individuals
experiencing both physical and psychological disabilities is provided, OSOT
maintains the position that physical and psychological disabilities should be
combined. Guidance should be sought from legal precedent. Further study is
recommended.
12.
OSOT supports the need for the interim determination to ensure access to early
rehabilitation which promotes maximal medical recovery for persons with traumatic
physical impairments and urges government to adopt this recommendation.
13.
An expert panel should be struck to investigate a 2(f) determination with in-depth
study regarding the psychiatric conditions typically arising from trauma.
14.
OSOT recommends that chronic pain disorder combined with a GAF score of 50 or
under be considered catastrophic.
15.
Should the government concur with the panel‟s findings about relying on the GAF
Assessment, OSOT submits that the GAF cut-off should be 50 rather than 40. A
GAF score of 50 describes “Serious symptoms (e.g., suicidal ideation, severe
obsessional rituals, frequent shoplifting) OR any serious impairment in
social, occupational, or school functioning (e.g., no friends, unable to keep
a job).” This would indicate a need for a substantive level and duration of
treatment
16.
In the spirit of assuring fairness so that children who are the most seriously injured
in motor vehicle accidents receive appropriate treatment, OSOT recommends that
the criteria 3 (i) (a) and (b) be replaced with:
a) Admission to a hospital and have positive findings on CT, MRI or PET scan or
any other braining imaging technology indicating intercranial pathology that is
the result of the accident.
17.
That if the KOSCHI is to be administered to a child after 6 months, the KOSCHI
should be administered by a physician with paediatric experience and a health
professional approved to complete an Attendant Care Assessment. Those
performing the Attendant Care Assessment must have clinical paediatric TBI and
paediatric attendant care assessment experience. All assessors should be also be
provided with all the relevant documentation available. The physician and/or
neuropsychologist input is needed in order to clarify the diagnosis, and that the
problems experienced are related to the accident. An Attendant Care Assessment
(which according to the SABS can only be done by an OT or Nurse) is needed in
order to obtain an objective measure of the attendant care required, including an
opinion on the number of hours during the waking day the child requires
supervision/actual help for physical, cognitive and/or behavioural impairments, and
21
an opinion on whether that care is considered normal parenting, or over and above
normal parenting, based upon the age of the client).
18.
OSOT supports further study of the psychometric properties of the KOSCHI. In this
regard, we propose that the GCS be used until such a time as the KOSCHI has
been shown to be a valid and reliable outcome measurement assessment tool.
19.
We recommend that children with subtle injuries that will become serious sources
of impairment over time will need access to a CAT attendant care/KOSHI or adult
CAT criteria assessment to be assessed for eligibility for CAT designation and
should have access to such assessment until the age of 21. OTs recognize that
some children will have a delayed manifestation sometimes spanning decades in
the case of infants whose impairments of cognition, emotion or behavioural
regulation may not fully express themselves until late teen years.
20.
OSOT recommends that children be assessed with the KOSCHI as early as is valid
so as to enable early identification of their status.
21.
That children with a significant pre-existing diagnosis at the time of the injury still
be considered catastrophic based on their presentation and clinical findings and not
be excluded from this group.
The Ontario Society of Occupational Therapists is pleased to extend the views of its members
on the final recommendations of the Expert Panel on Catastrophic Impairment.
Occupational therapists recognize the need for early, intensive medical and rehabilitation
interventions and the assistive devices, attendant care, home modifications, etc. that seriously
injured individuals often require – indeed OTs engage with these clients around these very
needs!
In light of the recent regulatory amendments, the Society is pleased that FSCO has moved
forward quickly to review the definition and determination process for serious injuries that
result in catastrophic impairments. We remain committed to assist as work proceeds to
further this initiative that will ensure that those most seriously injured in motor vehicle
accidents in Ontario receive the care and supports they need.
For further information or question, please contact:
Christie Brenchley, Executive Director
Ontario Society of Occupational Therapists
55 Eglinton Ave. E. Suite 210
Toronto, Ontario M4P 1G8
416-322-3011 ext 224
cbrenchley@osot.on.ca
22