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Here is an article from one of our Medical Expert Witness', who provided expertise in a case that we consulted on.
LIFE CARE PLANNER NURSE
Questions and Answers
Q. What is a life care plan? What does it include?
A. It’s a tool used to estimate medical and nonmedical needs of a person with a catastrophic injury or chronic illness over an estimated lifespan. Like every nursing plan of care, it’s designed to be dynamic. It’s based on published standards of practice, comprehensive assessment, data analysis, and research. A LCP may include medical needs and costs, such as physician and nursing care, medication, and therapies, and less-obvious things like goods and services to help with safe aging in place, architectural modifications, change in level of care anticipated, equipment/maintenance/replacement, transportation, furnishings-- anything that will incur costs related to the injury or illness.
Many LCP cases deal with people involved in workers compensation or liability claims with catastrophic conditions like traumatic brain injury, spinal cord injury, major trauma, major burns, chronic pain, major psychiatric diagnoses, or a combination of conditions. We 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.
Life Care Planning may be comprehensive or modified, depending on the needs of the party making the request; this is generally a plaintiff attorney seeking to obtain funds for a person’s needs, a defense attorney for an insurance carrier seeking to limit damages or to critique a plaintiff plan, or a trust officer whose charge is to manage funds for lifetime care. All of these clients need and want our expertise to explain the medical records, care planning, and future needs. It has been my experience that many --perhaps most-- attorneys do not 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.
Q. What kinds of cases would benefit from a life care plan?
A. Many life care plans involve plaintiff or defense worker’s compensation or liability claims with people suffering such catastrophic conditions as traumatic brain injury, spinal cord injury, multiple trauma, amputation, burns, chronic pain, or a combination of conditions. For example, many patients burned in explosions also suffer other injuries; persons with major trauma often have undetected brain injury that goes unnoticed early in their trauma care. I may also see children with birth injury or developmental condition, like Erb’s palsy, cerebral palsy, or mental disability, or elders whose care needs fall to family or a trust fund and may not involve litigation. Some life care planners specialize in vaccine cases or Veterans Administration cases.
Q. Do life care planners work only for plaintiff cases?
A. No. An insurance company may ask a life care planner to review medical records to provide a medical cost projection early in the care of a catastrophic injury, 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.
Q. What educational background 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 accredited college or university nursing programs, is valuable for assessing 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 has passed a national examination to demonstrate competence. Other certifications, such as for rehabilitation nursing, case management, disability management, legal nurse consulting, and other nursing specialty will demonstrate breadth and depth of expertise.
Attorneys often seek life care planners with extensive testifying experience. However, it’s important to know that the vast majority of life care planning cases are settled before trial. 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. A personal interview is helpful in assessing the life care planner’s personal presentation and willingness to testify.
Finally, ask for a sample plan. A poorly-written life care plan will not help you maximize the value of your case.
Q. How does a nurse life care planner prepare a life care plan?
A. The first step is to review and summarize 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, will help the nurse life care planner 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. The life care planner collaborates with members of the treating team and others as appropriate, and reviews 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. Pricing for all plan recommendations go into easily-understood tables, with references; obtaining current accurate pricing is critical and can be very labor-intensive.
Q. What records does a nurse life care planner review?
A. A nurse life care planner will want to see all available records. Sometimes when records have been compiled by a paralegal or other nonmedical person, they are incomplete because the compiler does not recognize the significance of each piece.
For example, EMS and emergency department records describe initial findings and mechanism of injury. While admission and discharge summaries are useful, they are often dictated by residents who are not completely up to date on the range of care and responses during the admission; it is not surprising to see conflicts and errors in them. The life care planner will 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). Outpatient therapy and orthotics/prosthetics records include periodic evaluations as well as notes from each session; problems, absences, and adherence to teaching are found here. For a child, school records, IEP (individual education plan), and pediatrician notes are important to assess current developmental state and function. Police accident reports would help the nurse 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 can 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. What is a medical cost projection? Is it like a life care plan?
A. Sometimes it’s too soon to do a comprehensive life care plan. For example, the injury may be too recent to know what the long-term effects would be and medical records may be scanty. In that case, a life care planner would likely recommend a medical cost projection, an overview of the usual effects of an injury or illness, long-term progress, and best estimates of the person’s anticipated needs. A medical cost projection is based on evidence-based standards of practice and can give a preliminary ballpark estimate of likely costs. This is useful for several reasons.
Q. Nurse life care planners can’t prescribe, can they?
A. Yes, we can. There is 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, but 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 the nurse practice act in every state. I am 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 as a certified nurse life care planner I will collaborate with members of the treating team, most life care plan components will not be involved with a health insurance contract and do not require physician signature. The evaluations and other aspects of my life care plans are within my professional licensure to prescribe.
Q. Are all life care planners the same?
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 course content on catastrophic or chronic conditions. I hold two national certifications in Nurse Life Care Planning; I also hold 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. My professional licensure, certification, experience, education, standards of practice, and ethics are backed by the nurse practice act. As a Certified Nurse Life Care Planner, therefore, I am within my scope of practice to prescribe the evaluations, equipment, consultations, and other interventions of my Life Care Plans. Other 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 are not able to assess outside of their specialties or, with the exception of physicians, promulgate a plan without having it signed off by a physician. Although a nurse life care planner will always collaborate with a treating physician if available, a registered nurse life care planner does not have that constraint, although some states may require physician review. It has been my experience that while physician life care planners may be good at estimating future medical costs related to a given injury, they are often unaware of the many, many other components needed in a comprehensive plan of care. This is especially true of the highest-cost items in most plans, home nursing and escalating care levels with aging.
There are numerous experts who are more than willing to provide testimony for medical malpractice and personal injury litigation cases. Finding the right one is crucial to the strength of your particular case.
Since 1983, Medical Advisors has assisted in the selection of expert witnesses in several thousand cases. Working with plaintiff and defense bar, we have provided medical opinions and testimony which have resulted in competent preparation and in-court support for cases involving medical malpractice, hospital negligence, personal injury, workers’ compensation and product liability.
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