This article is an introduction to life care planning and it’s relevance to physiatry and physiatric practice. It includes a discussion of life care planning, physiatry’s role within its history and evolution, and life care planning methodologies. It also discusses life care planning education and certification, how the core competencies of the physiatrist are particularly relevant and applicable to life care planning, and life care planning’s capacity to complement and diversify a clinical physiatric practice.
Joe G. Gonzales, MD, FAAPMR, CLCP, Andrea Zotovas, MD, FAAPMR
The following article was published in PM&R: The Journal of Injury, Function and Rehabilitation, Volume 6, Issue 2, 2014.
The health care industry is changing at an unprecedented rate. Increasing regulation, expanding compliance requirements, reduced practitioner discretion, and shrinking medical reimbursements are the predominate trends impacting the practice and the business of Physical Medicine and Rehabilitation.
As physiatrists seek new ways to contain administrative workloads, maintain practitioner autonomy, improve patient care/outcomes, and ensure the profitability of their practices, Life Care Planning stands out as a natural, flexible and rewarding addition to clinical physiatric practice.
LIFE CARE PLANNING
Life Care Planning is a seamless extension of physiatry. Life Care Planning is a process of applying methodological analysis to formulate diagnostic conclusions and opinions regarding physical and/or mental impairment and disability for the purpose of determining care requirements for individuals with permanent or chronic medical conditions.
Life Care Plans are comprehensive documents that objectively identify the residual medical conditions and ongoing care requirements of ill/injured individuals, and they quantify the ongoing costs of supplying these individuals with requisite medically-related goods and services throughout their durations of care.
Beyond serving as effective case management tools for ill/injured individuals, Life Care Plans provide litigators, insurance companies, trusts and courts with qualified, quantitative and referenceable bases upon which to substantiate the monetary value of medically-related compensatory damages. The ability to identify and substantiate damages with expert, objective and referenceable specificity improves outcomes for all parties.
Life Care Plans address both catastrophic and non-catastrophic conditions. In the authors’ experience and opinion, for the purposes of Life Care Planning, a catastrophic condition is defined as one in which an individual has lost significant capacity to perform some or all of the basic activities of daily living, while a non-catastrophic condition is one that results in structural abnormalities, pain, and/or functional deficits.
Common catastrophic conditions include: acquired brain injuries, birth injuries, major burns, multiple trauma and spinal cord injuries. Common non-catastrophic conditions include: amputations, burns, cervical, lumbar, and thoracic injuries, upper/lower extremity injuries, and major joint injuries—all conditions addressed by physiatrists as a customary part of daily practice.
The clinical objectives of a Life Care Plan are:
- to diminish or eliminate physical and psychological pain and suffering;
- to reach and maintain the highest level of function given an individual’s unique circumstance;
- to prevent complications to which an individual’s unique physical and mental conditions predispose them;
- to afford the individual the best possible quality of life in light of their condition.
These objectives, and the requisite skills, training and education necessary to accomplish them, make Life Care Planning a natural domain of Physiatry.
HISTORY, EVOLUTION & PHYSIATRY
The discipline of Life Care Planning was born of necessity. Prior to the mid-1970s, when a need arose to formulate/quantify future care, physicians or other rehabilitation professionals were often solicited to address three basic questions: 1) what is the subject’s condition; 2) what does the subject’s condition require; 3) and how much will the requirements cost over time? As one might imagine, there was significant variation in the quality, transparency and legitimacy of these assessments. At the time, the “industry” was in material need of generally accepted standards.
One of the individuals most acknowledged for answering the call of this necessity is Paul M. Deutsch, Ph.D., widely credited for establishing and formalizing the discipline now known as Life Care Planning. Dr. Deutsch, through publication and the establishment and/or involvement of various organizations, including the International Association of Rehabilitation Professionals, and the International Academy of Life Care Planners, developed curriculums, basic standards of practice, and eventually a professional credential for practitioner.
Over recent decades, organizations including the American Academy of Nurse Life Care Planners, and recently, the American Academy of Physician Life Care Planners, have established their own definitions, methods, standards and/or credentials, which may differ from one another, but are materially similar in most respects.
Throughout Life Care Planning’s history, physiatry has played a central role , yet less than 1% of Life Care Planners are qualified physicians. Non-physician Life Care Planners, like all experts, are bound by the limits of their professional licenses, and in the case of non-physician Life Care Planners, this limits their capacity to perform medical examinations, and to independently formulate diagnostic conclusions, opinions regarding impairment and disability, and recommendations for future care.
For these reasons, physiatrists have been heavily relied upon by non-physician Life Care Planners. Section one, chapter two of The Life Care Planning and Case Management Handbook, Third Edition, a central text of Life Care Planning, is entitled “The Role of the Physiatrist in Life Care Planning.” It states:
“For a Life Care Plan to appropriately provide for all the needs of an individual, the plan must have a strong medical foundation.” It continues: “Physicians specializing in physical medicine and rehabilitation (physiatrists) are uniquely qualified to provide a strong medical foundation for life care planning based on their training and experience in providing medical and rehabilitative services to individuals with disabilities. Physiatrists are, by their training, experienced in dealing with individuals who have catastrophic functional problems. Additionally, physiatrists are trained to anticipate the long term needs of their patients.”
Despite physiatry’s central role in Life Care Planning, until recently physiatrists have often relegated themselves to the margins of the discipline, serving primarily as “consultants” to non- physician Life Care Planners seeking guidance, support and/or “sign off” of their plans’ premises and conclusions. According to the authors’ experience, it is only recently when physiatrists, in material numbers, have begun entering the discipline as Life Care Planners themselves—a trend that is likely to continue into the foreseeable future given physiatrists’ unique qualifications, and the opportunity Life Care Planning offers physiatrists who seek to expand/diversify their clinical practices.
OVERVIEW OF METHODOLOGY
The methodologies for Life Care Planning are a framework of logical processes which can be applied to a wide variety of cases to determine conditions/illnesses and identify needs based upon reasonable degrees of medical probability. Variations in philosophy and approach exist among practitioners; however, these variations reflect the unique backgrounds of practitioners’ training and professional capacities.
At its most basic level, Life Care Planning is a three stage process which consists of collecting facts, formulating opinions, and producing conclusions.
Stage One: Includes collecting and reviewing medical records and performing personal interviews and/or physical examinations of subjects. It is in this stage when physician Life Care Planners consider objective findings (data from medical records, diagnostic studies, and information obtained during their own clinical examinations), and their impact on the subject’s current/future health and function.
Stage Two: Involves formulation of diagnostic conclusions, development of opinions regarding impairment, disability, comorbidities, life expectancy, and evidenced-based recommendations for future medically-related care. Future care categories customarily include items such as physician services, routine diagnostics, medications, labs, rehabilitation services, equipment and supplies, nursing and attendant care, environmental modifications, household services, and acute care services.
Stage Three: Requires conducting vendor surveys to obtain cost data for future care recommendations, and using such data to perform cost calculations that result in quantitative conclusions. Accepted methodologies require sample data from sources that are geographically proximate to the subject’s primary residence or location of probable care.
PHYSIATRY & LIFE CARE PLANNING
The unique qualifications of physiatrists afford them capacities that are not possessed by non-physician, and some cases, non-physiatric Life Care Planners. These capacities represent significant value to the subjects of Life Care Plans, as well as to the parties who commission their production.
The Capacity to Medically Examine
A physician’s capacity to perform medical examinations is, in most cases, outside the bounds of a non-physician’s professional licensure. The capacity to perform medical examinations is valuable, as medical examinations are often necessary to establish proper medical foundations for diagnostic conclusions and recommendations for future care.
The importance of a physician examination of a Life Care Plan’s subject is so meaningful, the Center for Medicare & Medicaid Services (CMS) requires the performance of a medical examination by a Life Care Plan’s authoring physician, as a prerequisite to accepting a Life Care Plan as a foundation for a Worker’s Compensation Medicare Set-aside Allocation. One reason for this is the information obtained by a physician during interview and examination can be processed through the unique information filter of physician interpretation that can, in turn, significantly impact a Life Care Plan’s medical foundations.
Relative to other medical specialties, physiatrists are particularly well suited to perform medical examinations for the types of cases which require Life Care Plans, as Physiatry is specifically geared towards the provision of holistic care and rehabilitation over time—exactly what a properly constructed Life Care Plan is designed to address.
The Capacity to Independently Formulate Medical Opinions
Life Care Plans are commissioned to identify and substantiate medical conditions and needs, that when quantified, define the value of medically-related compensatory damages in tort actions. It is therefore, advantageous for a Life Care Planner to possess the professional and legal capacity to independently formulate medical opinions. A physiatrist’s capacity in this regard, places him/her in a unique position among Life Care Planners, the majority of whom do not possess the capacity to independently formulate or substantiate the medical foundations of their Life Care Plans.
The advantage of being professionally and legally qualified to independently formulate medical opinions is significant. An advantage of this capacity is the practicality it affords a Life Care Planner in day-to-day practice. Most Life Care Planners are reliant upon treating physicians’ medical opinions; however, treating physicians are often unavailable, unwilling or unable to assist Life Care Planners in the development of their plans’ medical foundations. Many treating physicians do not have time to respond to requests for information—and if and when treating physicians do respond, they often afford limited time to meaningful consideration. In many cases, treating physicians are unable to properly assess overall medical status and need at the time of a Life Care Plan’s production.
The dilemma for non-physiatric Life Care Planners is succinctly summarized by Richard Paul Bonfiglio as follow: “the foundation of many life care plans is limited by the plan developer’s experience and the frequently marginal input from treating physicians. Especially in developing a plan for an individual with complex health care needs due to a catastrophic injury or illness, the life care planner and the treating physicians may have very little experience in dealing with a person with similar medical issues… ”
Physiatry’s Unique Applicability to Life Care Planning
Physiatrists are experts in the medical and physical treatment of disabling illness and injury , and have long been recognized as uniquely qualified among medical specialists to provide the scientific and medical foundations essential to the development of life care plans.”
A principle reason non-Physiatric Life Care Planners have sought guidance from physiatrists is many treating physicians specialize within narrow scopes of a subject’s care, and therefore, are not accustomed to fully assessing the total impact of a subject’s injury/illness on his/her overall health and function. Further, treating physicians are commonly unfamiliar with proper Life Care Planning methodology, which is important as it affects proper consideration of all relevant information, which affects the formulation of appropriate diagnostic and rehabilitation conclusions, which constitute proper foundations for future medical and rehabilitation needs.
Physiatrists, by the nature of their training, are holistic and comprehensive in their approach the assessment of medical and rehabilitation requirements and are well suited to determine what medical conditions remain relevant to a subject’s future care considerations.
The Capacity to Independently Defend Medical Opinion
A physician’s capacity to independently and credibly defend the medical opinions expressed in Life Care Plans—used as documentary evidence during depositions or trials—is unsurpassed.
According to Tracy R. Gunn in the Life Care Planning and Case Management Handbook, Third Edition: “It is the role of the physician to establish the existence of physical or mental impairment and it is inappropriate for the rehabilitation consultant to present opinion testimony as to the existence of a medical condition or its likely progression.”
From the perspective of those who commission the production of Life Care Plans, the ability to retain a single, uniquely qualified expert, as opposed to a non-physician Life Care Planner and one or more consulting physicians, represents significant savings in time, cost and administration. The ability for a single Life Care Planner to independently affect credibility, defensibility and economy enables physician Life Care Planners to provide significant value, relative to their non-physician counterparts.
EDUCATION & CERTIFICATION
While certification is not a requirement for Life Care Planning, rehabilitation professionals may elect to pursue additional education and credentialing to become a Certified Life Care Planner (CLCP). The benefits of certification include: education in regards to Life Care Planning methodologies, generally accepted standards, ethics and best practices, including familiarization with the legal procedures, and legal and administrative workflows.
According to the International Commission on Health Care, a body that governs the certification and credentialing of Life Care Planners, the Certified Life Care Planning Credential is designed to measure a candidate’s working knowledge of medical systems, associated disabilities, and treatment/maintenance protocol[s] required for an individual with a disability to sustain life within an acceptable comfort level.
The University of Florida, Kaplan College (online training leading to certification), Capital Law School paralegal program, the Institute for Medical Legal Education, IARP, and many other organizations have been pre-approved for training related to obtaining or maintaining certification.
Life Care Planning is a natural domain of Physiatry, and it is a discipline in which Physiatric practitioners maintain significant comparative advantages. Life Care Planning is a flexible, honorable and rewarding addition to clinical Physiatric practice. In a practice environment characterized by rapid centralization and diminishing reimbursement, Life Care Planning is a discipline to which many Physiatrists are beginning to dedicate serious attention.
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