CHRONIC CARE MANAGEMENT PLAN

SEIZURE DISORDER OVERVIEW

Epilepsy is the most common neurological condition in adolescents and
young adults. Epilepsy describes recurrent paroxysmal events (seizures)
due to self-activation of the cerebral cortex and gray matter -- with
excessive discharge of neurons leading to clinical symptomatology. It
affects 1-2% of the population and can be well controlled for about 80%
of patients with strict adherence to the prescribed treatment regimen.
However, it also has significant negative effects for adolescents in the
psychosocial and educational arenas that may also require Job Corps
staff interventions.

Seizure manifestations can vary according to location, anatomic
connections, and functions of the central nervous system pathways
involved. Such discharges may trigger either partial or generalized
events. Epilepsy is predominantly a condition of youth. It may be a
symptom of an underlying disorder (e.g., malformation, scarring of the
brain, or a tumor, or may be idiopathic (genetic predisposition) --
presumably secondary to some faulty neurotransmission. Thus, over the
decades, several methods of classification of seizures have been
postulated and the current one is called the International
Classification of Epileptic Seizures \[see Epilepsia 22:489-501, 1981\].

Simply put, seizures are either partial (synonymous with symptomatic and
cortical, e.g., a jacksonian seizure) or generalized (synonymous with
idiopathic, e.g., petit mal, and grand mal seizures). The progression of
a seizure is characterized by several temporal components or phases:
prodrome, aura, ictal, then postictal. Since the manifestations of
seizures are predictable according to their origin within the central
nervous system (CNS), the taking of an accurate history is paramount as
the symptoms experienced by the patient tell much. The signs and
behaviors described by witnesses to the seizure are also crucial for
understanding the origin and method of spread of the ictal discharges in
the CNS.

Treatment of epileptic seizures involves drug therapy specific to the
type of seizure and there are numerous medications now available for
treatment and these control over 80% of cases allowing most patients to
maintain a normal lifestyle. If drug therapy fails, treatment may
include surgical removal of a demonstrated lesion to attempt to stop
seizures.

Plans should be in place to manage breakthough seizures and to deal with
any prolonged seizure (status epilepticus). Precautions for daily living
and match to trade must be included in the student's action CCMP (see
examples).

CHRONIC CARE MANAGEMENT PLAN

### SEIZURE DISORDER

#### OUTREACH AND ADMISSIONS PERIOD

Please provide us with the following information.

1.  List current medications and/or treatment including dosage and
    frequency prescribed.

2.  Has applicant been compliant with medications and treatment? If no,
    please explain.

3.  List past hospitalizations including dates, reason for admission and
    include discharge summaries.

4.  What is current status and prognosis?

5.  When was last appointment?

6.  Will the applicant need to continue follow up under your care? If
    yes, please list the date and/or frequency of follow up
    appointments.

7.  In your opinion, will the applicant be able to self-manage
    medications unsupervised and participate in a vocational training
    program. If no, please explain.

8.  In your opinion, will the applicant be appropriate to reside in a
    dormitory style residence with minimal supervision? If no, please
    explain.

9.  Are there any restrictions or limitations related to this specific
    illness?

10. What is the applicant's smoking history?

11. Does the applicant use hormonal contraception? (females only)

##  

## Does the applicant have health insurance documentation?

Please sign below and return the form in the attached addressed
envelope.

###### Print Name and Title Signature

###### Phone Date

For any questions, please call

### Admission Counselor/Health and Wellness Staff 

> **Phone**

CHRONIC CARE MANAGEMENT PLAN

### SEIZURE DISORDER

**Goals:**

1.  Enhance employability by optimizing control of seizures.

2.  Educate the student regarding recognition of symptoms and
    self-management.

3.  Reduce expose to risk of injury should a seizure occur.

4.  Optimize anticonvulsant therapy.

5.  Implement regularly scheduled follow-up visits.

+----+-----+----------------------------------------------------------+
| #  |     |                                                          |
|  * |     |                                                          |
| *C |     |                                                          |
| AR |     |                                                          |
| EE |     |                                                          |
| R  |     |                                                          |
| PR |     |                                                          |
| EP |     |                                                          |
| AR |     |                                                          |
| AT |     |                                                          |
| IO |     |                                                          |
| N  |     |                                                          |
| PE |     |                                                          |
| RI |     |                                                          |
| OD |     |                                                          |
| ** |     |                                                          |
+----+-----+----------------------------------------------------------+
| #  | #   | #                                                        |
|  * | **N |                                                          |
| *Y | O** |                                                          |
| ES |     |                                                          |
| ** |     |                                                          |
+----+-----+----------------------------------------------------------+
| #  | #   | # *                                                      |
|    |     | *Establish an Seizure Disorder Action Plan for student** |
+----+-----+----------------------------------------------------------+
| #  | #   | # Offer the s                                            |
|    |     | tudent a Medical Identification bracelet/necklace/anklet |
+----+-----+----------------------------------------------------------+
| #  | #   | # Visits every 2-3 months                                |
+----+-----+----------------------------------------------------------+
| #  | #   | # Assess vocational training match                       |
+----+-----+----------------------------------------------------------+
| #  | #   | # Mandatory TUPP/smoking cessation enrollment            |
+----+-----+----------------------------------------------------------+
| #  | #   | # Annual influenza vaccination in October or November    |
+----+-----+----------------------------------------------------------+
| #  | #   | # Emergency response plan                                |
+----+-----+----------------------------------------------------------+
| #  | #   | # **Educate student on Seizure Disorder precautions**    |
|    |     |                                                          |
|    |     | ## **Transportation**                                    |
|    |     |                                                          |
|    |     | ## No driving unless seizure                             |
|    |     | s well controlled for an interval specified by state DMV |
|    |     |                                                          |
|    |     | ## Wear bicycle helmets and protective gear              |
|    |     |                                                          |
|    |     | # Stay cle                                               |
|    |     | ar of the platform edge when using public transportation |
|    |     |                                                          |
|    |     | ## **Bathroom safety**                                   |
|    |     |                                                          |
|    |     | ## Showering instead of bathing                          |
|    |     |                                                          |
|    |     | ## Shatterproof glass in shower doors                    |
|    |     |                                                          |
|    |     | ## Shatterproof bottles (shampoo etc.)                   |
|    |     |                                                          |
|    |     | ## No electrical equipment near water                    |
|    |     |                                                          |
|    |     | # Non-skid strips in shower stall                        |
|    |     |                                                          |
|    |     | ## **Kitchen safety**                                    |
|    |     |                                                          |
|    |     | ## Cook with a partner                                   |
|    |     |                                                          |
|    |     | ## Use back burners of the stove to prevent burns        |
|    |     |                                                          |
|    |     | ## Use shatterproof containers                           |
|    |     |                                                          |
|    |     | ## Limit use of knives and other sharp kitchen utensils  |
+----+-----+----------------------------------------------------------+
| #  | #   | ###### Educate student about lifestyle choices           |
|    |     |                                                          |
|    |     | ## Weight management                                     |
|    |     |                                                          |
|    |     | ## Encourage                                             |
|    |     |  whole fruits, vegetables, low fat milk, increased fiber |
|    |     |                                                          |
|    |     | ## Avoid soda and fruit juices                           |
|    |     |                                                          |
|    |     | -   Encourage aerobic physical activity (exercise 30     |
|    |     |     minutes per day, 5 days per week)                    |
|    |     |                                                          |
|    |     | ## Avoid sedentary lifestyle (limit TV)                  |
|    |     |                                                          |
|    |     | ## Avoid smoking                                         |
|    |     |                                                          |
|    |     | -   Limit alcohol use                                    |
+----+-----+----------------------------------------------------------+
| #  | #   | ###### Educate student on                                |
|    |     |  seizure disorder management as it relates to employment |
+----+-----+----------------------------------------------------------+

+----+-----+----------------------------------------------------------+
| #  |     |                                                          |
|  * |     |                                                          |
| *C |     |                                                          |
| AR |     |                                                          |
| EE |     |                                                          |
| R  |     |                                                          |
| DE |     |                                                          |
| VE |     |                                                          |
| LO |     |                                                          |
| PM |     |                                                          |
| EN |     |                                                          |
| T  |     |                                                          |
| PE |     |                                                          |
| RI |     |                                                          |
| OD |     |                                                          |
| ** |     |                                                          |
+----+-----+----------------------------------------------------------+
| #  | #   | #                                                        |
|  * | **N |                                                          |
| *Y | O** |                                                          |
| ES |     |                                                          |
| ** |     |                                                          |
+----+-----+----------------------------------------------------------+
| #  | #   | # **Monitor adherence issues**                           |
|    |     |                                                          |
|    |     | # Medication regimen                                     |
|    |     |                                                          |
|    |     | ## Medication refills                                    |
|    |     |                                                          |
|    |     | ## Routine medical care                                  |
|    |     |                                                          |
|    |     | ## Urgent medical care                                   |
|    |     |                                                          |
|    |     | ## Environmental control                                 |
|    |     |                                                          |
|    |     | ## Self-monitoring                                       |
|    |     |                                                          |
|    |     | ## Physiotherapy                                         |
|    |     |                                                          |
|    |     | ## Rest                                                  |
|    |     |                                                          |
|    |     | ## Exercise                                              |
|    |     |                                                          |
|    |     | ## Nutrition                                             |
|    |     |                                                          |
|    |     | ## Tobacco, alcohol, drug use                            |
+----+-----+----------------------------------------------------------+
| #  |     |                                                          |
| ** |     |                                                          |
| CA |     |                                                          |
| RE |     |                                                          |
| ER |     |                                                          |
|  T |     |                                                          |
| RA |     |                                                          |
| NS |     |                                                          |
| IT |     |                                                          |
| IO |     |                                                          |
| N  |     |                                                          |
| PE |     |                                                          |
| RI |     |                                                          |
| OD |     |                                                          |
| ** |     |                                                          |
+----+-----+----------------------------------------------------------+
| #  | #   | # Conduct a Wellness Center exit inte                    |
|    |     | rview approximately two weeks before program completion. |
+----+-----+----------------------------------------------------------+
| #  | #   | # Identify potential sources of primary health ca        |
|    |     | re, and specialty care if needed, in the work community. |
+----+-----+----------------------------------------------------------+
| #  | #   | # Ob                                                     |
|    |     | tain signed HIPAA authorizations for the transfer of stu |
|    |     | dent health records to identified health care providers. |
+----+-----+----------------------------------------------------------+
| #  | #   | # Assist the student in enrolling or maintaining enr     |
|    |     | ollment in a public or private health insurance program. |
+----+-----+----------------------------------------------------------+
| #  | #   | # Provide the student with a copy                        |
|    |     | of the SF-93, SF-88, immunization records, and a copy of |
|    |     |  the chronic care management plan, including flowsheets. |
+----+-----+----------------------------------------------------------+
| #  | #   | # Provide the student with an ade                        |
|    |     | quate amount of medication(s) and supplies at departure. |
+----+-----+----------------------------------------------------------+

# 

**See Seizure Disorder Management Flow Sheet for tracking patient
visit.**

**See Treatment Guideline for Seizures for additional guidance.**

**CHRONIC CARE MANAGEMENT PLAN FLOWSHEET**

SEIZURE DISORDER

<table>
<colgroup>
<col style="width: 19%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 3%" />
<col style="width: 8%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="14"><h3 id="student-name">Student Name:</h3></td>
</tr>
<tr class="even">
<td colspan="2"><h3 id="sex-m-or-f">Sex: M or F</h3></td>
<td colspan="6"><h3 id="date-of-birth">Date of Birth:</h3></td>
<td colspan="6"><h3 id="date-of-entry">Date of Entry:</h3></td>
</tr>
<tr class="odd">
<td colspan="14"><h3 id="type-of-seizure-disorder">Type of Seizure
Disorder:</h3></td>
</tr>
<tr class="even">
<td colspan="14"><h3 id="co-morbid-conditions">Co-Morbid
Conditions:</h3></td>
</tr>
<tr class="odd">
<td colspan="14"><h3 id="medications-on-entry">Medications on
Entry:</h3></td>
</tr>
<tr class="even">
<td colspan="14"><strong>Seizure disorder EPISODE</strong></td>
</tr>
<tr class="odd">
<td><h4 id="date">Date</h4></td>
<td colspan="2"><h4 id="time">Time</h4></td>
<td colspan="3"><h4 id="length-of-seizure">Length of Seizure</h4></td>
<td colspan="4"><h4 id="events-before-seizure">Events before
seizure</h4></td>
<td colspan="4"><h4
id="description-of-seizure-and-events-after-seizure">Description of
seizure and events after seizure</h4></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"><h4 id="section-38"></h4></td>
<td colspan="4"><h4 id="section-39"></h4></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"><h4 id="section-40"></h4></td>
<td colspan="4"><h4 id="section-41"></h4></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"><h4 id="section-42"></h4></td>
<td colspan="4"><h4 id="section-43"></h4></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"><h4 id="section-44"></h4></td>
<td colspan="4"><h4 id="section-45"></h4></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"><h4 id="section-46"></h4></td>
<td colspan="4"><h4 id="section-47"></h4></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"><h4 id="section-48"></h4></td>
<td colspan="4"><h4 id="section-49"></h4></td>
</tr>
<tr class="even">
<td colspan="14"><h4 id="medication-management">MEDICATION
MANAGEMENT</h4></td>
</tr>
<tr class="odd">
<td><strong>Date Prescribed</strong></td>
<td colspan="3"><strong>Medication and Dosage</strong></td>
<td colspan="2"><strong>Date Changed</strong></td>
<td colspan="8"><h4 id="comments">Comments</h4></td>
</tr>
<tr class="even">
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="8"><h4 id="section-50"></h4></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="8"><h4 id="section-51"></h4></td>
</tr>
<tr class="even">
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="8"><h4 id="section-52"></h4></td>
</tr>
<tr class="odd">
<td colspan="14"><h4 id="seizure-disorder-managment">SEIZURE DISORDER
MANAGMENT</h4></td>
</tr>
<tr class="even">
<td rowspan="6"><blockquote>
<p><strong>Every Visit or as indicated</strong></p>
</blockquote></td>
<td colspan="3"><strong>Date</strong></td>
<td><h4 id="section-53"></h4></td>
<td colspan="2"><h4 id="section-54"></h4></td>
<td colspan="2"><h4 id="section-55"></h4></td>
<td colspan="2"><h4 id="section-56"></h4></td>
<td><h4 id="section-57"></h4></td>
<td><h4 id="section-58"></h4></td>
<td><h4 id="section-59"></h4></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Hearing loss or vision concerns</strong></td>
<td><h4 id="section-60"></h4></td>
<td colspan="2"><h4 id="section-61"></h4></td>
<td colspan="2"><h4 id="section-62"></h4></td>
<td colspan="2"><h4 id="section-63"></h4></td>
<td><h4 id="section-64"></h4></td>
<td><h4 id="section-65"></h4></td>
<td><h4 id="section-66"></h4></td>
</tr>
<tr class="even">
<td colspan="3"><strong>Neuromotor problems</strong></td>
<td><h4 id="section-67"></h4></td>
<td colspan="2"><h4 id="section-68"></h4></td>
<td colspan="2"><h4 id="section-69"></h4></td>
<td colspan="2"><h4 id="section-70"></h4></td>
<td><h4 id="section-71"></h4></td>
<td><h4 id="section-72"></h4></td>
<td><h4 id="section-73"></h4></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Soiling or incontinence</strong></td>
<td><h4 id="section-74"></h4></td>
<td colspan="2"><h4 id="section-75"></h4></td>
<td colspan="2"><h4 id="section-76"></h4></td>
<td colspan="2"><h4 id="section-77"></h4></td>
<td><h4 id="section-78"></h4></td>
<td><h4 id="section-79"></h4></td>
<td><h4 id="section-80"></h4></td>
</tr>
<tr class="even">
<td colspan="3"><strong>Sleep disorder</strong></td>
<td><h4 id="section-81"></h4></td>
<td colspan="2"><h4 id="section-82"></h4></td>
<td colspan="2"><h4 id="section-83"></h4></td>
<td colspan="2"><h4 id="section-84"></h4></td>
<td><h4 id="section-85"></h4></td>
<td><h4 id="section-86"></h4></td>
<td><h4 id="section-87"></h4></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Medication side effects</strong></td>
<td><h4 id="section-88"></h4></td>
<td colspan="2"><h4 id="section-89"></h4></td>
<td colspan="2"><h4 id="section-90"></h4></td>
<td colspan="2"><h4 id="section-91"></h4></td>
<td><h4 id="section-92"></h4></td>
<td><h4 id="section-93"></h4></td>
<td><h4 id="section-94"></h4></td>
</tr>
</tbody>
</table>