Life Care Planning: Building the Record Foundation

The Life Care Plan Foundation

A life care plan is a document that outlines the future care needs of an individual with a catastrophic injury or chronic illness. It's used in personal injury litigation, workers' compensation, and disability planning.

The foundation of every life care plan is the medical record.

If the record review is incomplete or inaccurate, the life care plan is unreliable. This post shows you how to build the record foundation for a defensible life care plan.

What Is a Life Care Plan?

A life care plan is a dynamic document based on published standards of practice, comprehensive assessment, data analysis, and research. It provides a concise, organized plan for the current and future needs of an individual with a catastrophic injury or chronic illness.

Key components:

• Projected evaluations: Medical, therapeutic, diagnostic
• Projected therapeutic modalities: Physiotherapy, occupational therapy, speech therapy, counseling
• Projected medications: Current and future medications
• Projected supplies: Durable medical equipment, supplies, orthotics
• Projected home care: Home modifications, attendant care, respite care
• Projected transportation: Wheelchair van, transportation services
• Projected educational/vocational: Special education, vocational training
• Projected recreational: Adaptive sports, social activities

The life care planner's job: Identify these needs, estimate their frequency and duration, and assign costs.

The foundation: The medical record.

The Record Review Framework for Life Care Planning

Phase 1: Identify the Index Event

Goal: Understand the injury or illness that necessitates the life care plan.

What to document:

• Date and mechanism of injury (or diagnosis of illness)
• Initial diagnosis
• Initial treatment
• Prognosis at the time of injury/diagnosis

Questions to ask:

• What was the initial injury or diagnosis?
• What was the expected prognosis?
• What complications have arisen?

Example:

• Index event: Motor vehicle accident on January 15, 2020
• Initial diagnosis: Traumatic brain injury (severe), spinal cord injury (C5 complete)
• Initial treatment: Hospitalization, surgery, rehabilitation
• Prognosis: Permanent tetraplegia, cognitive impairment

Phase 2: Build the Treatment Timeline

Goal: Understand what treatment has been provided to date.

What to document:

• Hospitalizations (dates, duration, reasons)
• Surgeries (dates, procedures, complications)
• Rehabilitation (inpatient, outpatient, duration, goals, outcomes)
• Medications (current and past, doses, responses)
• Therapies (physiotherapy, occupational therapy, speech therapy, psychology)
• Medical equipment (wheelchair, hospital bed, communication device)
• Home care (nursing, attendant care)
• Complications (infections, pressure sores, contractures)

Create a table:

Phase 3: Identify Current Status

Goal: Understand the individual's current medical, functional, and cognitive status.

What to document:

• Medical status: Current diagnoses, current symptoms, current medications
• Functional status: Mobility, ADLs, IADLs, communication, cognition
• Cognitive status: Memory, attention, executive function, behavior
• Psychological status: Depression, anxiety, PTSD, adjustment
• Social status: Living situation, family support, vocational status

Sources of information:

• Recent medical records
• Functional capacity evaluations
• Neuropsychological testing
• Home assessments
• Vocational assessments

Example:

• Medical status: Tetraplegia (C5 complete), neurogenic bladder and bowel, recurrent UTIs, pressure ulcer history
• Functional status: Wheelchair-dependent for mobility, requires assistance for all ADLs, independent for some IADLs with adaptive equipment
• Cognitive status: Memory impairment, slowed processing speed, executive dysfunction
• Psychological status: Depression (treated with sertraline), anxiety
• Social status: Lives at home with spouse, not employed

Phase 4: Identify Future Needs

Goal: Project what the individual will need for the rest of their life.

Categories of future needs:

1. Medical Care

• Physician visits: Primary care, specialist visits (neurology, physiatry, urology, etc.)
• Diagnostic testing: Imaging, lab work, urodynamics
• Hospitalizations: Expected rehospitalizations for complications
• Surgeries: Expected future surgeries (e.g., tendon releases, shunt revisions)

Questions to ask:

• How often does the individual need to see each specialist?
• What diagnostic tests are needed and how often?
• What complications are expected and how often will they require hospitalization?
• What surgeries are anticipated?

2. Therapies

• Physiotherapy: Maintenance therapy to prevent contractures, maintain strength
• Occupational therapy: Training for new equipment, home modifications
• Speech therapy: Cognitive rehabilitation, communication training
• Psychology: Counseling for depression, anxiety, adjustment

Questions to ask:

• What therapies are currently needed?
• What therapies will be needed in the future?
• How often and for how long?

3. Medications

• Current medications: List all, with doses and frequencies
• Future medications: Anticipate new medications for complications

Questions to ask:

• What medications is the individual currently taking?
• Are these medications expected to continue lifelong?
• What new medications might be needed?

4. Durable Medical Equipment

• Wheelchair: Manual or power, expected replacement every 5 years
• Hospital bed: Expected replacement every 10 years
• Communication device: If needed, expected replacement every 5 years
• Other equipment: Standing frame, exercise equipment, etc.

Questions to ask:

• What equipment is currently used?
• What is the expected lifespan of each item?
• What maintenance and repairs are expected?

5. Supplies

• Catheters: Intermittent catheters, expected use 4-6 per day
• Incontinence supplies: Diapers, pads, expected use 6-8 per day
• Wound care supplies: If history of pressure ulcers
• Other supplies: Nutrition supplements, medications, etc.

Questions to ask:

• What supplies are currently used?
• How often are they used?
• What is the cost per unit?

6. Home Care

• Attendant care: Hours per day, tasks
• Nursing care: If needed, hours per day, tasks
• Respite care: If family provides care, respite hours

Questions to ask:

• How much attendant care is needed?
• What tasks does the attendant perform?
• Is family providing care? If so, how much respite is needed?

7. Home Modifications

• Accessibility modifications: Ramp, widened doorways, accessible bathroom, elevator
• Future modifications: As the individual ages, additional modifications may be needed

Questions to ask:

• What modifications have been made?
• What additional modifications are needed?
• What is the expected cost?

8. Transportation

• Wheelchair van: If needed, expected replacement every 7-10 years
• Transportation services: If van not owned, cost of transportation services

Questions to ask:

• Does the individual own a wheelchair van?
• If not, what transportation services are used?

9. Vocational/Educational

• Vocational training: If the individual can work, what training is needed?
• Supported employment: If the individual can work with support, what support is needed?
• Special education: If the individual is a child, what educational services are needed?

Questions to ask:

• Can the individual work?
• If so, what training or support is needed?
• If not, what is the basis for this conclusion?

Phase 5: Identify Life Expectancy

Goal: Determine the individual's life expectancy to project costs over their lifetime.

Sources:

• Life expectancy tables (general population)
• Life expectancy tables for specific conditions (e.g., spinal cord injury, traumatic brain injury)
• Medical literature on life expectancy for the individual's specific condition and complications

Questions to ask:

• What is the individual's current age?
• What is their life expectancy based on general population tables?
• How does their condition affect life expectancy?
• What complications further reduce life expectancy?

Example:

• Current age: 35
• General population life expectancy: 45 additional years (age 80)
• Spinal cord injury (C5 complete) life expectancy: 30 additional years (age 65)
• Complications (recurrent UTIs, pressure ulcers): May further reduce life expectancy

Phase 6: Assign Costs

Goal: Estimate the cost of each future need.

Sources:

• Local provider rates
• National cost databases
• Medicare/Medicaid fee schedules
• Vendor quotes

What to document:

• Unit cost (e.g., cost per physician visit, cost per catheter)
• Frequency (e.g., visits per year, catheters per day)
• Duration (e.g., lifelong, for 10 years)
• Inflation adjustment (e.g., medical inflation rate)

Example:

• Physiatry visit: $300 per visit, 2 visits per year, lifelong
• Intermittent catheters: $2 per catheter, 5 per day, lifelong
• Wheelchair: $5,000, replacement every 5 years, lifelong

Common Pitfalls in Life Care Planning Record Reviews

1. Incomplete Record Review

The mistake: You miss records that document important complications or treatments.

The fix: Request all records. Build a comprehensive timeline. Identify gaps.

2. Not Identifying All Current Needs

The mistake: You focus on medical needs and miss equipment, supplies, or home care needs.

The fix: Review all categories of needs systematically.

3. Not Projecting Future Complications

The mistake: You project current needs forward but don't anticipate future complications.

The fix: Review medical literature on expected complications for the individual's condition.

4. Not Adjusting for Life Expectancy

The mistake: You project costs to general population life expectancy without adjusting for the individual's condition.

The fix: Use condition-specific life expectancy data.

5. Not Documenting the Basis for Projections

The mistake: You project future needs without citing the medical record or literature.

The fix: Document the basis for each projection (e.g., "Physiatry note dated 01/15/24 recommends annual follow-up").

Key Takeaways

1. The medical record is the foundation of the life care plan.
2. Identify the index event, build the treatment timeline, and identify current status.
3. Project future needs across all categories: medical care, therapies, medications, equipment, supplies, home care, home modifications, transportation, vocational/educational.
4. Identify life expectancy based on condition-specific data.
5. Assign costs based on local rates and document the basis for each projection.
6. Avoid common pitfalls: incomplete record review, missing current needs, not projecting complications, not adjusting for life expectancy, not documenting the basis.

What's Next?

In our next post, we'll begin our Canada-specific series with "Ontario SABS Files: Medical Records Requirements" — the first in our Canadian legal series.

This post is part of our series on medical record review for life care planners. For more, see our 60 AI Prompts for IME Physicians Reviewing Medical Records.

Questions for Readers:

• What's the most challenging life care plan you've built?
• How do you project future complications?
• What sources do you use for life expectancy data?