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Applying life care planning principles in acute situations
Applying Life Care Planning Principles in Acute Situations Patricia McCollom, MS, RN, CRRN, CDMS, CCM, CLCP, FIALCP
I
n autumn of 2004, a US stop-loss carrier requested consultation regarding their in-house catastrophic case-management program. Their market was self-funded Employee Retirement Income Security Act (ERISA) plans with fewer than 10,000 lives. Although the company was committed to providing case management, they had problems with data gathering and communication with various third-party administrators (TPAs) for lack of a consistent flow of work and communication among all parties concerned. Their question: “Is case management provided by a stop-loss carrier viable in this circumstance?”
The Process During the consultation period, all policies and procedures related to case management were reviewed. Recommendations after this review included development of individualized work flow processes to meet individual TPA needs and inclusion of the employer (plan developer) in the process of decision making for catastrophic cases. The mantra of the challenge was, “When the case is catastrophic, the rules change.” With this approach, they believed that the viability of a catastrophic case management plan was strong and effective to control the wise use of available resources. Two TCM 66
September/October 2006
employer groups were selected for a demonstration project to evaluate the viability and efficacy of this plan. An algorithm (Figure 1) was created for each group to serve as the individualized work flow process. This work flow process defines accountability and responsibility for the case manager in a unique process that includes the employer. The Outcomes The following case studies represent specific outcomes of the demonstration project and clarify creative alternatives that provided individualized care to the patients in need.
Patient 1, Ms E, had been diagnosed with hepatitis C. This 42-year-old woman lived in a small community in California and was being cared for by a large hospital system. She was “double listed” for a liver transplant. Upon initial contact for assessment, it was learned that Ms E was toxic from medications and required home care, which to date had not been provided. Her husband was continuing to work fulltime and could not provide the care she needed. A sister from the Midwest had traveled to the home to assist. The attending physician said he did not think that Ms E would survive a trans-
Figure 1. Algorithm: Catastrophic Case Management
Company or TPA refers all patients with total brain injury, spinal cord injury, 20% burns, transplants, or any case as requested by the employer to stop loss case manager
Case Manager Notifies Contact of Referrals from Employer Directly Case Management Assessment A. Consent obtained B. Communicate with patient/family, as possible C. Communicate with providers D. Determination of medical necessity, as appropriate E. Communicate findings to contact at TPA
Case Management Plan Developed A. Options considered B. Collaboration with employer regarding benefit flexibility C. Budget established D. Letters to provider, plan, patient, as appropriate E. UM activities and certification processes completed, per plan requirements
Case Management Plan Presented to Employer and TPA A. Discussion of eligibility B. Acceptance of case management plan by employer C. Contracts coordinated by stop-loss carrier for specialty networks, if required
Case Management Plain Implemented A. Case manager implements plan B. Plan status reported to employer and TPA, including financial report as needed or minimum monthly in writing (e-mail/verbal contact, as needed) C. Case closure occurs with case management plan completion (will notify contact for both case closure or should they need to continue services) Criteria for Case Closure: 1. Health/wellness achieved 2. Patient stable and able to self-manage 3. Patient dies September/October 2006
TCM 67
plant attempt but supported her desire to do so. In the second home contact, the sister said that if Ms E could return to the Midwest, multiple family members would be available to provide care. Family discussions were held, and the husband agreed that the best place for his wife was with her family. Discussions also were held with Ms E’s employer, who supported any care necessary for this employee. Review of the health plan revealed that travel costs could be reimbursed. A “life-care plan” that included relocation for care and transfer of care from the attending physician to a local transplant team in the Midwestern city was then developed. The budgetary portion of the plan included the specialty network discounts, which were available to the employer/plan no matter where the patient was geographically located. The plan was implemented with Ms E’s return to her hometown and family, health care provided through the local university transplant team, and home care provided, with supervision, by the family. Within 24 hours of arrival in the Midwestern city, Ms E was evaluated by the new health-care team and admitted to the university hospital for acute liver failure. Her health was controlled, and she returned home for ongoing monitoring and weekly clinic visits. She was able to spend 3 weeks visiting with family, seeing familiar sights, and eating whatever foods she wanted. At the beginning of the fourth week, she went to her regular clinic visit and was again admitted, this time in full liver failure. The treatment team indicated that she was too ill for a transplant, and palliative care was the treatment of choice. The family agreed, and her husband traveled to be at her side. When Ms E died, she was comfortable and had her family with her. The life-care plan had included the risk of death, in this case, because of the advanced stage of her illness. The plan also provided a clear picture of her health condition and the potential situaTCM 68
September/October 2006
tions that were faced, within the provisions of the plan. It was the employer, after reviewing the plan, who made the choice to spend the dollars available in the patient’s best interest. Patient 2 was a 28-year-old man who was injured while riding a motorcycle that collided with a car. Mr S experienced severe brain injury and multiple fractures of the right leg. He had received emergency and acute care at a large hospital system and was transferred to a well-known rehabilitation center for ongoing care. His referral came at the point discharge was pending from the rehabilitation center. When Mr S was assessed, a number of individuals were included: the patient, his father, significant other, physician, and social worker. All agreed that Mr S required significant ongoing care for recovery to continue. In review of the employer’s health plan, the only apparent choice was for discharge to a skilled nursing facility. Skilled nursing facilities were reviewed and evaluated, however, with the conclusion that such facilities would not meet this patient’s needs and, in fact, could worsen his health status. A specialty treatment program for persons with brain injury within the geographical area was identified instead as part of the life-care plan. Because of his multiple cognitive and physical needs, the specialty program was recommended in lieu of the benefit for skilled care. The employer agreed and proactively, the facility was approved for a 100-day period, with close monitoring of progress by the case manager. The case manager also made an on-site visit to the facility to meet with the patient and his father. Plans were made for discharge, including input from the social worker, and outpatient treatment was established. Mr S returned to his home, with patient physical therapy, monthly visits to the rehabilitation center, and communitybased support for cognitive monitoring. After his discharge, he adhered to the plan and, within 2 months, was using public transportation independently and handling his finances independently, with family members serving oversight functions. As of this summer,
he is planning to return to work in a volunteer situation to evaluate his potential for return to competitive employment. Conclusion The principles of life-care planning— assessment, research, and data analysis—may be applied in a number of different settings. In these situations, the principles were used in catastrophic cases to formulate plans for use of available resources to meet individual needs. The necessary ingredients for success must first include an employer or health plan that is committed to the health and well-being of those they insure. The plan must understand the potential risks associated with the complex care/needs for those with catastrophic diagnoses and must be willing to be flexible within the plan’s defined parameters. Second, the TPA must demonstrate concern for the individual and recognize the alternatives for flexibility within a self-funded plan. In this day of chaotic and fragmented health care, this demonstration project identified that caring and individual planning can benefit all parties concerned by understanding that although the rules change with catastrophic cases, positive outcomes can occur when resources are used in patients’ best interest. ❏ Patricia McCollom, MS, RN, CRRN, CDMS, CCM, CLCP, is the president and nurse consultant for Management Consulting and Rehabilitation Services, Inc., and LifeCare Economics, Ltd., in Ankeny, Iowa. Reprint orders: E-mail authorsupport@ elsevier.com or phone (toll-free) 888-834-7287; reprint no. YMCM 418 doi:10.1016/j.casemgr.2006.06.007
I
n autumn of 2004, a US stop-loss carrier requested consultation regarding their in-house catastrophic case-management program. Their market was self-funded Employee Retirement Income Security Act (ERISA) plans with fewer than 10,000 lives. Although the company was committed to providing case management, they had problems with data gathering and communication with various third-party administrators (TPAs) for lack of a consistent flow of work and communication among all parties concerned. Their question: “Is case management provided by a stop-loss carrier viable in this circumstance?”
The Process During the consultation period, all policies and procedures related to case management were reviewed. Recommendations after this review included development of individualized work flow processes to meet individual TPA needs and inclusion of the employer (plan developer) in the process of decision making for catastrophic cases. The mantra of the challenge was, “When the case is catastrophic, the rules change.” With this approach, they believed that the viability of a catastrophic case management plan was strong and effective to control the wise use of available resources. Two TCM 66
September/October 2006
employer groups were selected for a demonstration project to evaluate the viability and efficacy of this plan. An algorithm (Figure 1) was created for each group to serve as the individualized work flow process. This work flow process defines accountability and responsibility for the case manager in a unique process that includes the employer. The Outcomes The following case studies represent specific outcomes of the demonstration project and clarify creative alternatives that provided individualized care to the patients in need.
Patient 1, Ms E, had been diagnosed with hepatitis C. This 42-year-old woman lived in a small community in California and was being cared for by a large hospital system. She was “double listed” for a liver transplant. Upon initial contact for assessment, it was learned that Ms E was toxic from medications and required home care, which to date had not been provided. Her husband was continuing to work fulltime and could not provide the care she needed. A sister from the Midwest had traveled to the home to assist. The attending physician said he did not think that Ms E would survive a trans-
Figure 1. Algorithm: Catastrophic Case Management
Company or TPA refers all patients with total brain injury, spinal cord injury, 20% burns, transplants, or any case as requested by the employer to stop loss case manager
Case Manager Notifies Contact of Referrals from Employer Directly Case Management Assessment A. Consent obtained B. Communicate with patient/family, as possible C. Communicate with providers D. Determination of medical necessity, as appropriate E. Communicate findings to contact at TPA
Case Management Plan Developed A. Options considered B. Collaboration with employer regarding benefit flexibility C. Budget established D. Letters to provider, plan, patient, as appropriate E. UM activities and certification processes completed, per plan requirements
Case Management Plan Presented to Employer and TPA A. Discussion of eligibility B. Acceptance of case management plan by employer C. Contracts coordinated by stop-loss carrier for specialty networks, if required
Case Management Plain Implemented A. Case manager implements plan B. Plan status reported to employer and TPA, including financial report as needed or minimum monthly in writing (e-mail/verbal contact, as needed) C. Case closure occurs with case management plan completion (will notify contact for both case closure or should they need to continue services) Criteria for Case Closure: 1. Health/wellness achieved 2. Patient stable and able to self-manage 3. Patient dies September/October 2006
TCM 67
plant attempt but supported her desire to do so. In the second home contact, the sister said that if Ms E could return to the Midwest, multiple family members would be available to provide care. Family discussions were held, and the husband agreed that the best place for his wife was with her family. Discussions also were held with Ms E’s employer, who supported any care necessary for this employee. Review of the health plan revealed that travel costs could be reimbursed. A “life-care plan” that included relocation for care and transfer of care from the attending physician to a local transplant team in the Midwestern city was then developed. The budgetary portion of the plan included the specialty network discounts, which were available to the employer/plan no matter where the patient was geographically located. The plan was implemented with Ms E’s return to her hometown and family, health care provided through the local university transplant team, and home care provided, with supervision, by the family. Within 24 hours of arrival in the Midwestern city, Ms E was evaluated by the new health-care team and admitted to the university hospital for acute liver failure. Her health was controlled, and she returned home for ongoing monitoring and weekly clinic visits. She was able to spend 3 weeks visiting with family, seeing familiar sights, and eating whatever foods she wanted. At the beginning of the fourth week, she went to her regular clinic visit and was again admitted, this time in full liver failure. The treatment team indicated that she was too ill for a transplant, and palliative care was the treatment of choice. The family agreed, and her husband traveled to be at her side. When Ms E died, she was comfortable and had her family with her. The life-care plan had included the risk of death, in this case, because of the advanced stage of her illness. The plan also provided a clear picture of her health condition and the potential situaTCM 68
September/October 2006
tions that were faced, within the provisions of the plan. It was the employer, after reviewing the plan, who made the choice to spend the dollars available in the patient’s best interest. Patient 2 was a 28-year-old man who was injured while riding a motorcycle that collided with a car. Mr S experienced severe brain injury and multiple fractures of the right leg. He had received emergency and acute care at a large hospital system and was transferred to a well-known rehabilitation center for ongoing care. His referral came at the point discharge was pending from the rehabilitation center. When Mr S was assessed, a number of individuals were included: the patient, his father, significant other, physician, and social worker. All agreed that Mr S required significant ongoing care for recovery to continue. In review of the employer’s health plan, the only apparent choice was for discharge to a skilled nursing facility. Skilled nursing facilities were reviewed and evaluated, however, with the conclusion that such facilities would not meet this patient’s needs and, in fact, could worsen his health status. A specialty treatment program for persons with brain injury within the geographical area was identified instead as part of the life-care plan. Because of his multiple cognitive and physical needs, the specialty program was recommended in lieu of the benefit for skilled care. The employer agreed and proactively, the facility was approved for a 100-day period, with close monitoring of progress by the case manager. The case manager also made an on-site visit to the facility to meet with the patient and his father. Plans were made for discharge, including input from the social worker, and outpatient treatment was established. Mr S returned to his home, with patient physical therapy, monthly visits to the rehabilitation center, and communitybased support for cognitive monitoring. After his discharge, he adhered to the plan and, within 2 months, was using public transportation independently and handling his finances independently, with family members serving oversight functions. As of this summer,
he is planning to return to work in a volunteer situation to evaluate his potential for return to competitive employment. Conclusion The principles of life-care planning— assessment, research, and data analysis—may be applied in a number of different settings. In these situations, the principles were used in catastrophic cases to formulate plans for use of available resources to meet individual needs. The necessary ingredients for success must first include an employer or health plan that is committed to the health and well-being of those they insure. The plan must understand the potential risks associated with the complex care/needs for those with catastrophic diagnoses and must be willing to be flexible within the plan’s defined parameters. Second, the TPA must demonstrate concern for the individual and recognize the alternatives for flexibility within a self-funded plan. In this day of chaotic and fragmented health care, this demonstration project identified that caring and individual planning can benefit all parties concerned by understanding that although the rules change with catastrophic cases, positive outcomes can occur when resources are used in patients’ best interest. ❏ Patricia McCollom, MS, RN, CRRN, CDMS, CCM, CLCP, is the president and nurse consultant for Management Consulting and Rehabilitation Services, Inc., and LifeCare Economics, Ltd., in Ankeny, Iowa. Reprint orders: E-mail authorsupport@ elsevier.com or phone (toll-free) 888-834-7287; reprint no. YMCM 418 doi:10.1016/j.casemgr.2006.06.007