Q&A on Life Care Plans

I know that many –perhaps most– of the people reading this think they know what a nurse life care planner is and does already. And they might. But if there’s one thing I’ve learned in my work, it’s that you can always learn something new. Maybe this is your chance! Here are some questions I get asked by attorneys, trust officers, and others.

Q. What’s a life care plan? What’s in it?

A. My life care plans are tools to estimate medical and nonmedical needs of a person with a catastrophic injury or chronic illness over his lifetime. They’re dynamic, meant to be flexible as time passes. It’s based on my full assessment, published standards of practice, data analysis, and research. A given LCP could include medical needs and costs, such as physician and nursing care, medicines, and therapies, and less-obvious things like goods and services to help with safe aging in place, architectural modifications, change in level of care, equipment/maintenance/replacement, transportation, furnishings– anything in someone’s life that will incur costs related to the injury or illness.

Many LCP cases deal with people in workers comp or liability claims. I see catastrophic conditions like traumatic brain injury, spinal cord injury, major trauma, major burns, chronic pain, major psychiatric diagnoses, or a combination of conditions. I also see children with birth injury or developmental condition like cerebral palsy or mental disability, or elders whose care needs fall to a family member, guardian, or a trust fund and may not involve litigation.

Q. Isn’t Obamacare going to take care of all this anyway?

A. The Affordable Care Act mandates insurance coverage for doctor visits, medicines, or hospitals for a great many people with a great many medical conditions. How that all works out in the long run, well, we’ll see.

However, most of the needed goods and services in a life care plan are not covered by insurance anyway. Equipment for home, kitchen, and bathroom safety, ramps, transportation, educational and support services, wheelchairs, braces, artificial limbs, visiting nurse and other kinds of home care, assisted living, and nursing home care are so important for life-long care, and the ACA won’t cover them. As a matter of fact, home health care, assisted living, and skilled care makes up the bulk of the costs for any catastrophic injury over the life of the injured party.

Q. Who wants one?ICU c pt

A. It’s been my experience that many –perhaps most– attorneys don’t have a full appreciation of the extent of future needs or their costs, particularly in complex cases with many potential complications and anticipated changes with aging. My clients are almost always attorneys, because life care plans are important in legal proceedings. For example, most of my cases are worker’s compensation or liability claims with people suffering catastrophic conditions like traumatic brain injury, spinal cord injury, multiple trauma, amputation, burns, chronic pain, or a combination of conditions. People burned in explosions usually have other injuries from the blast; persons in car wrecks often have undetected brain injury that goes unnoticed early in their trauma care. I also see children with birth injury or developmental conditions, like Erb’s palsy, cerebral palsy, or mental disability. Elders whose care needs fall to family or a trust fund need help in figuring out what the needs are and how to spend the money wisely, even if there’s no litigation. Some life care planners specialize in vaccine cases or Veterans Administration cases.

Q. Don’t life care planners work only for plaintiffs?

A. No. Insurance companies ask me to review medical records early in the care of a catastrophic injury, to figure out what costs might be (see “Medical cost projections”) so funds can be reserved for expected care. Defense cases benefit from having a certified nurse life care planner explain the medical issues. The certified nurse life care planner will also review a plaintiff life care plan to look at the planner’s qualifications, check for errors, identify any excessive or incomplete recommendations, and evaluate plan methodology and foundation. In some cases, defense and plaintiff life care planners are asked to collaborate to develop a final plan. Finally, trust officers for elders, disabled children, or others may retain a nurse life care planner to help make the most efficient use of limited funds, plan for changes anticipated with aging, and guide case management. (SeeIs it too late to create a life care plan for my grandfather?“) 

Q. What should an attorney look for when choosing a life care planner?

A. Ask for proof of current, unrestricted registered nurse licensure. A registered nurse with a broad background in nursing, preferably with nursing degree(s) from an accredited college or university nursing program, is best to assess the injured person’s function, cognition, and current situation. A certified nurse life care planner has education and experience in case management and life care planning, and passed a national examination to demonstrate competence. Other certifications, such as for rehabilitation nursing, case management, disability management, legal nurse consulting, or other nursing specialty demonstrate breadth and depth of expertise.

Attorneys often think they want life care planners with extensive testifying experience.  Look for someone who’s presented at professional meetings frequently. A nurse life care planner with a good methodology, confident manner, and excellent speaking ability to explain to the court may have had few or no opportunities to have done so outside of deposition. 

Finally, ask for a sample plan. A poorly-written life care plan won’t help you maximize your case’s value.

Q. How does a nurse life care planner prepare a life care plan?

medical recordsA. My first step is reviewing and summarizing all available medical records, including all hospital records (see below). Then a personal visit with the injured person and family, at their home if possible, helps me assess their knowledge of the injury and its treatment, the individual’s current function, adaptive technology in use, home modifications, transportation, home safety, resources, coping, goals, and stress levels. I review the literature on related standards of practice, available technology, recommendations for care and equipment, potential complications, changes expected with aging, and any other appropriate issues, to form a plan of care and develop recommendations. Then I reach out to members of the treating team and others as appropriate (this generally isn’t possible with defense cases). I put all pricing for every recommendation into easily-understood tables, with references; obtaining current accurate pricing can be very labor-intensive but there’s no substitute for current, accurate work. 

Q. What records does a nurse life care planner review?

A. I want to see all available records. Records compiled by a paralegal or other nonmedical person are often incomplete because the compiler does not recognize the significance of each piece of the puzzle. (See: “Do you read those PT records? No?”) 

For example, EMS and emergency department records describe initial findings and mechanism of injury. While admission and discharge summaries are useful, they’re often dictated by residents who are not completely up to date on the range of care and responses during the admission; it isn’t surprising to see conflicts and errors in them carried forward from previous electronic records. I want to review all team progress notes, laboratory and diagnostic studies, physician and nursing order sheets, nursing records, medication administration records, consultant notes, and procedure notes (e.g., surgery, invasive testing) so I can identify errors there, too. 

Outpatient therapy and orthotics/prosthetics records include periodic evaluations; I find good information on problems, absences, and adherence to teaching here. 

For a child, school records, IEP (individual education plan), and pediatrician’s notes help me assess current developmental state and function. 

Police accident reports help me to understand possible mechanisms of injury, and to assess for signs of disability that may not have been evident during initial hospitalization. Finally, billing records reveal valuable information on physicians and treatment plans that may need to continue in a life care plan. Reconciling billing with medical records can disclose missing records, too.

Q. Nurses can’t prescribe, can they? 

A. Yes, we can.  There’s no legal requirement in any state in the US for all goods and services for a patient’s care to be prescribed by a physician. It’s important not to confuse an insurance plan’s requirement to have a physician prescription for a billable product or service, or the legal requirement for physicians to prescribe medication, with the registered nurse life care planner’s ability to assess and recommend. The law requires some things (such as medications and surgery) to be prescribed or performed by physicians or advanced nurse practitioners. Insurance companies require that most goods and services be prescribed by physicians only for cost control purposes. My registered nurse professional licensure, certification, experience, education, standards of practice, and ethics are backed by nurse practice acts and the ANA Scope and Standards of Nursing Practice that apply to all RNs. I’m qualified, as a registered nurse life care planner, to prescribe a plan of care after assessing the patient’s response to injury or illness. Although I’ll work with members of the treating team, most life care plan components won’t be involved with a health insurance contract and don’t require physician signature. The evaluations and other aspects of my life care plans are within my professional licensure to prescribe. (SeeDo you think RN life care planners can’t prescribe? Read this!”)

Q. So, if you’ve seen one life care planner, you’ve seen them all, right?

A. No. I am a Certified Nurse Life Care Planner, CNLCP, a professional registered nurse with education and expertise in preparing and reviewing life care plans, including medical record review, research, legal aspects, and particular content on catastrophic or chronic conditions. I’ve earned two national certifications in Nurse Life Care Planning, national certification in rehabilitation nursing, two national certifications in case management, and national certification as a legal nurse consultant. As a registered nurse, I base my independent practice on nursing process and nursing diagnosis, backed by my license and the Nurse Practice Act. I collaborate with treating physicians to specify items requiring physician prescription by law, such as surgery, prescription medications, and some types of equipment. As a CNLCP, however, it’s within my scope of practice to prescribe the evaluations, equipment, consultations, and other interventions I specify in my Life Care Plans. 

Other kinds of life care planners take education in the LCP process and applicable laws; they come from a variety of backgrounds such as physical therapy, vocational counseling, medical assisting, social work, and even some physicians; they’re not able to assess outside of their specialties or, with the exception of physicians, offer a plan without having it signed off by a physician. 

Q. Why don’t I just ask the doctor what’s needed?Aging LTC

A. It’s been my experience that while physician life care planners may be good at estimating future physician charges related to a given injury, they’re often unaware of the many, many other components needed in a comprehensive plan of care, like hospital fees, anesthesia, therapy, and equipment. And they don’t know much about the most important– and most expensive– components of all!

The highest-cost items in most plans are for home nursing and escalating care levels with aging. Physicians aren’t licensed to prescribe nursing hours of care; RNs are. Physicians don’t do home visits to assess home-care needs; RNs do. When you consider that the biggest dollar values in Life Care Plans are for nursing care, it’s clear how important this is. And physicians are rarely, if ever, tuned into the other costs that insurance doesn’t cover (see “Obamacare,” above).

When you have a case with long-term medical needs, you need an expert. We are the experts in medical damages over life expectancy. Contact Howland Health Consulting at 866-604-9055 or via our contact form now and take advantage of our free first-look consultation and new client discount!

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