FAQs | Life Care Planning

“The life care plan is a dynamic document based upon published standards of practice, comprehensive assessment, data analysis, and research, which provides an organized, concise plan for current and future needs with associated costs for individuals who have experienced catastrophic injury or have chronic health care needs” (International Academy of Life Care Planners, 2003. Established during the 2000 Life Care Planning Summit).

Life care planning is a consistent process for evaluating the patient and disability in order to establish all of the needs dictated by the onset of that disability. Consistency refers to the application of the process of evaluation and does not suggest that similar disabilities will all receive similar recommendations to meet established needs. Careful consideration is given to the goals, needs and interest of the patient, the needs of the family and the realities of the geographic region in which the patient resides. The process is based on published standards, tenets, methodologies and principles. It takes into consideration the medical records, the patient and family perspective, the treatment team, the clinical practice guidelines, relevant research literature and the carefully established medical, case management and rehabilitation foundation.

A life care plan is a tool of case management and can be used in consultation with patients, families, rehabilitation professionals, and catastrophic case managers. The life care plan specifies the long-term medical, psychological, and rehabilitation needs of an individual throughout his/her lifetime. It has application in the non-judicial as well as judicial arena. It is utilized as a preventative plan for disability management outside the judicial setting. Within the judicial and insurance settings it is used to establish an accurate profile of the long term needs, recommendations and costs associated with the onset of the particular disability involved.

Though the elements of life care plans are generally consistent when compared to one another, the content within each area is individualized to the needs of the patient and family. In addition to the items themselves, each associated cost, replacement schedule, dates of implementation and suspension, and the name of the professional making the recommendation are clearly identified. Depending upon the specific needs of the patient, the following areas may be addressed within the life care plan:

• • Projected evaluations
  • Projected therapeutic modalities
  • Medication
  • Diagnostic testing and educational assessments
  • Supply needs
  • Wheelchair needs
  • Wheelchair accessories and maintenance
  • Home care or facility-based care needs
  • Projected routine future medical care
  • Orthopedic equipment needs
  • Projected surgical treatment or other aggressive medical care
  • Orthotic or prosthetic requirements
  • Transportation needs
  • Home furnishings and accessories
  • Architectural renovations
  • Aids for independent function
  • Leisure or recreational equipment

The role of the life care planner is that of educator, not advocate. A planner must maintain objectivity and base recommendations upon the medical records, clinical interview and history with the patient and family, interaction with the medical and health related professional treatment team, relevant clinical practice guidelines, relevant research literature as well as the opinions of consulting team members (physicians, therapists, etc.). The responsibility of the life care planner is to set forth attainable rehabilitation goals and to assure that all parties involved in the process understand why specific items are included, how/when services should be provided, and how the plan is best implemented. As an educator, the planner must be able to clearly communicate the nature of a patient’s disability, the residual functional limitations, and the effects of the disability throughout the patient’s life expectancy.

With its foundation in rehabilitation, life care planning attracts board certified professionals from diverse fields of practice, including rehabilitation counseling, rehabilitation nursing, rehabilitation psychology, physiatry, case management, and other areas. (See CHCC, The Commission on Health Care Certification, for specific qualifications and requirements). Although not required, it is helpful for a life care planner to also be board certified as a case manager or at least have experience in the actual case management and implementation of life care plans.

In addition to achieving certification in their primary disciplines, many professionals choose to pursue board certification in life care planning (CLCP) which is granted by the International Commission on Health Care Certification.

Courts have sought the specialized knowledge of life care planners so that they, and juries, are better able to understand the long-term effects of catastrophic injuries and the associated economic damages of such cases. It is important to understand that when choosing a life care planner two factors may override all others in making a decision. First, does the life care plan represent a document which answers questions rather then raise them? Is it clear, understandable, well documented and well presented? Second, does the life care planner have a reputation for being able to present this information in an understandable fashion to all parties concerned, from the report, through deposition and into trial? The most knowledgeable expert will do little good if they are unable to communicate that knowledge to the individuals and juries to whom the information must be directed.

Items within a life care plan reflect the needs of the individual and the recommendations necessary to fulfill those needs. Needs and associated recommendations cannot be restricted to those items allowed either by collateral funding sources or by covered insurance. Funding issues are not considered when developing a life care plan. Rather, needs are identified and the costs associated with necessary care and/or rehabilitation are cited according to the prevailing charges in the community within which an individual resides.

The life care plan addresses every aspect of a disability from onset through the end of life expectancy. By the nature of the task this requires developing information across a broad range of medical and health related professionals. No single physician or rehabilitation professional completing a life care plan can do so in a vacuum. Each must reach out to establish a medical, case management and rehabilitation foundation for the plan. This cannot be done without consulting with other team members, working with clinical practice guidelines and relevant research literature. Life care planners should not work in isolation, and when choosing a planner this may well be one of the first questions the referral source may wish to explore.

Yes. The most respected life care planners follow a consistent approach to plan development with each and every case. These steps involve:

• Comprehensive review of records and supportive documentation.
• Clinical interview and history with the patient and whenever possible a family member or significant contact who knew the patient pre-morbidly as well as post-morbidly.
• Interaction with the medical and health related treatment team to obtain answers to questions not established in the medical records review.
• Research to develop relevant clinical practice guidelines to further establish needs and recommendations as well as support medical and case management foundation.
• Research on relevant research literature to further establish needs and recommendations as well as support medical and case management foundation.
• Where necessary establish further data through staffing with consulting specialists.

In order to most effectively and accurately analyze the needs of patients, life care planners must employ a consistent methodology and approach to the task.

Life care planners deliberately and methodically organize, evaluate, and interpret patient-specific information. In each of the steps listed above the goal is to link the recommendations to the supportive documentation.

Absolutely not. Regardless of the orientation of the referral source (e.g., plaintiff attorney, defense attorney, hospital administrator, etc.), respected life care planners employ a systematic approach to case analysis and base recommendations upon the demonstrated needs of each individual as dictated by the onset of a disability. Variations between the plans of individuals with similar disabilities will occur because of unique case variables, but the methodology for analysis should remain consistent.

The fundamental process does not change when approaching the life care planning process from a defense perspective. Consistency in the approach is still critical and the plan one develops should not be influenced by the referral source. Nevertheless, the life care planner does not always have the opportunity to perform a clinical interview and history with the patient and a family member. Also, they will typically not be allowed any interaction with the treating health care team. So how can these issues be overcome? If the case has been referred sufficiently early enough in the process, the following steps are recommended.

First, the relevant clinical interview and history questions for the patient and a family member should be developed and presented to the referral source for use in deposition. This will allow the life care planner to obtain much of the necessary data.

Second, the professional can participate in developing questions for the deposition of the plaintiff’s life care planner. Make sure all of the plaintiff’s experts file is attached including all their clinical interview notes and supportive documentation. The goal is to use them as your professional eyes and ears in the interview process. Review the interview carefully to see if they accurately linked what was said to the conclusions reached in the plan.

Also, develop questions for the medical and health related professional depositions as a means of receiving answers to questions relative to the life care plan. With these steps, much of what would otherwise have been lost as the result of not being able to perform a full evaluation can be regained. These are not the only solutions but they represent some of the best.

The practice of life care planning has been influenced by extensive research that has taken place over the past several decades. This research has identified four critical areas of the life care plan where a strong Foundation must be established: Medical Foundation; Rehabilitation Foundation; Case Management Foundation; and Psychological Foundation.

A strong Medical Foundation is established by:

1. Drawing direct links between the medical records and recommendations in the plan.
2. Writing the Medical and Allied Health treatment team members with plan questions not answered in the existing records.
3. Utilizing consulting specialists.
4. Utilizing Clinical Practice Guidelines.

A strong Rehabilitation Foundation is established by:

1. Effective use of the medical and rehabilitation records through careful linking of this information to plan recommendations.
2. Writing the Medical and Allied Health treatment team members with plan questions not answered in the existing records.
3. Utilizing consulting specialists.
4. Utilizing Clinical Practice Guidelines.
5. Using Research Literature.

Strong Case Management and Psychological Foundations are established by:

1. Effective use of the medical and rehabilitation records through careful linking of this information to plan recommendations.
2. Writing the Medical and Allied Health treatment team members with plan questions not answered in the existing records.
3. Writing the current case manager on the file.
4. Utilizing consulting specialists.
5. Using Clinical Practice Guidelines.

The costs associated with these areas cannot be accurately predicted. The future date, severity, duration or intensity of a complication cannot be known. The supportive documentation simply does not exist in the literature to allow this kind of accuracy to go into a plan. The jury can be informed that the plan is preventative in nature and took potential complications into consideration in its design but complications cannot be ruled out. Future technology developed to meet a given individual’s needs has also been an area difficult to predict in a life care plan. Up to this time we have only been able to say that the plan is limited to acknowledging that the only money available in the plan for future technology is that amount set aside for existing items that will be replaced by a future technology. Since we do not know what that will cost we cannot know the extent to which that item is covered. Current research is underway to compare plans from twenty years ago to current plans to at least begin to explore this issue.

At this time, costs of complications and future technology are not included in the final cost analysis of life care plans. However, it is important for life care planners and case managers to inform decision-makers that there is potential for development of complications, as well as invention of future technology, which could have an impact even though they have not been included in the life care plan projections.

A life care planner does not attempt to “predict” future events, but bases the plan upon all of the steps outlined in the process above. This includes but is not limited to review of the medical records, recommendations from members of the individual’s current treatment team, clinical practice guidelines, and evidence-based research relative to the individual’s disability and level of function. In addition, an extensive review of the medical records and clinical interview allow the planner to appreciate the individual’s medical and rehabilitation history while understanding current needs. Recommendations within the life care plan must have a basis in known medical, case management and rehabilitation outcomes as documented within the research literature.

The short answer is, “Yes.” Many challenges under Daubert and Frye have occurred and have been successfully overturned. In several instances these challenges were lost and in each instance, these occurred because the life care planner did not follow the methodology as outlined within these FAQ’s. That is, these professionals relied only upon their own expertise and usually were found to have overstepped that expertise by entering into the medical arena or the psychological arena and making a diagnosis they were unqualified to make.

The following are key components in answering the four questions under Daubert, (six if you are in Texas) or being prepared under Frye:

1. Always expect a challenge and be prepared to properly educate all parties on the life care planning process step by step.
2. Carefully educate your referral source so they are prepared to act as a first line of defense in answering the judge’s questions. The most significant problems occur when the referral source is not sufficiently prepared for a challenge and cannot answer the questions.
3. Where possible have the testimony proffered, giving the Life Care Planner an opportunity to answer the questions that are being raised.
4. Always have extensive documentation. For example, do not just refer to the clinical practice guidelines, research literature, home health practice act for the particular state, Federal minimum standards for Home Health Practices or the Centers for Medicaid and Medicare standards for reimbursement on CNA’s, LPN’s and RN’s. Instead, have the relevant materials with you at the time of testimony.
5. In addition to having the relevant materials, the life care planner should set up a bullet point chart outlining relevant points to go over for themselves and the referral source.
6. Documenting the acceptance of life care planning among the relevant scientific community is not difficult. Life care planning is endorsed by a number of professional associations and has been the focus of a broad range of peer reviewed journal articles. In addition, in 2004 a determination was made by CORE (Commission on Rehabilitation Education) stating that all State University Masters programs would be required to demonstrate relevant life care planning curriculum in order to qualify for certification.
7. In short be well informed, well prepared and know the relevant questions under Daubert and Frye and be prepared to answer them. Know the nature of the motion that has been filed and be prepared to answer that. Neither the referral source nor the life care planner should take this lightly. It is important to the case, to the referral source and it is critically important, to in its impact on the consulting career of the life care planner.

Discovery Life Care Planning & Rehabilitation Services, LLC has spent years gathering clinical practice guidelines, rehabilitation and medical research relevant to catastrophic disabilities to establish medical foundation/case management foundation for each line item in the life care plan. Our professional staff is highly trained in the incorporation of this research into the life care planning process in a manner that allows for information and education that provides the best possible evidence to guide care plan recommendations.

Reliability is comprised of the dependability and consistency of the life care planning process to yield similar results under similar circumstances. However, this does not mean that life care plans for two different clients with the same disability will be “carbon copies.” While the basic elements of a reliable life care plan should be reproducible; they are also tailored specifically to meet the needs of the individual client. Therefore, relevant research, literature and recommendations are particular to the individual case.

Validity is case specific. A standard, “valid” life care plan for all people who have a spinal cord injury does not exist. Each life care plan must be valid for the individual for whom it was developed. If life care planning is a valid process, then a good life care plan will accomplish its mission: to decrease the frequency and severity of medical complications for a particular patient, avoiding case management by crisis intervention, and improving the patient’s overall quality of life. Establishing the validity of the life care planning process shows that the basic tenets of life care planning are sound. The Foundation for Life Care Planning Research has conducted and published research projects on the reliability and validity of the life care planning process and funds doctoral dissertation research in this area as well.

Information and recommendations in a life care plan are not based solely on one professional’s opinion or experiences. Instead they are based on reasonable, ethical and appropriate analysis of client specific needs. Clinical practice guidelines related to the specific disability can serve as recommendations for patient care and disability management allowing for the most beneficial medical and therapeutic interventions along with the recommendations made by a treating or consulting medical doctor. While clinical practice guidelines provide valuable information related to specific disabilities, it is important that the life care planner understand both the benefits and limitation of their use. Clinical practice guidelines may not account for all of the individual variations that patients present and as such are not meant to be automatic inclusions without adequate research and assessment of the particular case. For example, many such published guidelines do not take into account aging with an injury over time but focus on short-term outcomes post rehabilitation. At Discovery Life Care Planning & Vocational Rehabilitation, LLC, our professional staff is trained in the area of clinical practice guidelines and their application to individual cases. As such, we are able to effectively and accurately apply these guidelines as well as explain and educate a judge and jury regarding their validity and relevance to each individual case.

Knowledge of the research literature and its impact on the life care planning process is an important part of the work done at Discovery Life Care Planning & Rehabilitation Services, LLC. In addition to life care planning, we are likewise committed to contributions in the field of life care planning through research in our own practice and via the support of other professionals through the Foundation for Life Care Planning Research. Understanding and thus incorporating the most recent information and advances in rehabilitation are critical to the development of a comprehensive life care plan. Our commitment to this aspect of care provides our clients with the highest quality life care plan supported by the research literature.

The Foundation for Life Care Planning Research has forged associations with the University of Florida, Georgia State University and the Medical College of Virginia, Virginia Commonwealth University. In each instance these associations are with the Departments of Rehabilitation, which work with the Foundation to achieve its primary mission statement of supporting research on the process of Life Care Planning. The Foundation was established in 2002 as a nonprofit research group, with a primary focus on research on the reliability and validity of the Life Care Planning process. Although that remains an important consideration for the Foundation, the Board has broadened the scope of the mission to consider any well-developed research design in Life Care Planning that advances the field and/or makes a significant contribution to the population of disabled individuals Life Care Planners seek to serve.

Visit our Introduction to Life Care Planning section and select a link about life care planning. Additional information can also be found in our Research Article and Research Design and Stats sections.