Samples for Success: Life Care Plans from Practicing Life Care Planners

Samples for Success: Life Care Plans from Practicing Life Care Planners

First Edition

First Edition

January 2015

Author: Victoria Powell Cover Design: Jim Gaffney Production: Victoria Powell Proof Ready: Wendie Howland Index: Victoria Powell

Powell, Victoria.

Sample for Success: Life care plans for practicing life care planners / By Victoria Powell. – 1st ed.

Includes Index Summary: “Empowering readers facing similar experiences, Samples for Success provides background information and things to consider about injury, disease process or associated litigation. This resource is for new and experienced life care planners faced with writing a plan for an injury or illness that is unfamiliar.” –Provided by publisher.

ISBN-13:978-0692209318 (Remington Publishing) ISBN-10:069220931X

Copyright © 2015 by Remington Publishing. All rights reserved.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without prior written permission of the publisher. For information on bulk purchases or corporate premier sales, please contact Remington Publishing. Call 501-778-7999 or email sales@lifecareplanningbooks.com.

Samples for Success: Life Care Plans from Practicing Life Care Planners

By Victoria Powell

Remington Publishing Arkansas, USA

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Disclaimer This book is designed to share various examples of actual life care plans from authentic and respected sources. Reprinted material is quoted with permission and sources are indicated.

Our intended audience includes anyone with a role in planning future complex medical care, such as life care planning students, legal nurse consultants, case managers, other medical and allied health professionals, and legal professionals with an interest in medicallyrelated cases.

The book is meant to enlighten, empower, and educate the reader by bringing together many examples of plan layout, narrative format, stock language, as well as offer insight into the judicial process, critical thinking elements, and potential resources for a particular case type.

The contributed plans are shared to give the reader a framework, potential plan resources and references for developing life care plans.

Information in this book is based solely on the contributing life care planners’ opinions, preferences, experiences, and relationships with the individuals for whom the plan was written. The reader is urged not to rely on any reference or resource materials without independent verification.

The spirit of this publication is about examining, comparing, and contrasting to educate the reader on how to think about life care planning.

We want to enhance readers’ critical thinking and provide new ideas. This book offers a general framework to life care plan development. While a reader may find and choose to apply elements found in these exemplars, our intention is not to provide howto, step-by-step, one-size-fits-all templates.

It is also not our purpose or intent to provide full and complete information on how to identify or present every possible recommendation for a given injury or condition.

Readers’ research for life care plan development should not be limited to the contents of this textbook. They are urged to seek out and evaluate information from all available sources to expand their life care planning knowledge and to apply those results to their clients’ unique needs and plans.

Reasonable effort has been made to publish reliable data and information. The publisher, authors and editor assume no responsibility regarding the validity of included materials or for the consequences of their use. Remington Publishing and its employees accept no responsibility for the activities of those mentioned or endorse any of the life care planners or their respective life care planning services. The publisher does not further endorse or recommend any specific software, template, or resource shared in this book.

Remington Publishing, the author, editor, and its contributors are not engaged in rendering legal advice, nor shall the book be used as a reference or citation for any future life care plans. Readers should always seek competent legal professional advice if indicated. Remington Publishing, editors, and contributors shall have neither liability nor responsibility in whole or in part to any person or entity with respect to any loss or damage caused, or alleged to have been caused, directly or indirectly, by the information contained in this book.

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Table of Contents Disclaimer ..................................................................................................................................................... 1 Preface .......................................................................................................................................................... 7 About the Author ......................................................................................................................................... 9 About the Contributors .............................................................................................................................. 11 Kathy Allison, MS, PT, CLCP................................................................................................................ 11 Barbara Bate, RN-BC, CCM, CRRN, CNLCP, LNCC, MSCC ................................................................... 11 Cynthia Bourbeau, RN, CRRN, CCM, CNLCP....................................................................................... 12 Alisa Dayanim, RN, MSN, CRRN, CLCP, CNLCP................................................................................... 12 Shelene Giles, MS, BSN, BA, RN, CRC, CNLCP, MSCC, LNCC .............................................................. 12 Wendie Howland, MN, RN-BC, CRRN, CCM, CNLCP, LNCP-C, LNCC .................................................. 13 Alex Karras, OTR, CRC, CCM, MSCC, CLCP ......................................................................................... 14 Kimberly Kushner MSN, BSN, RN, CPNP, CLCP, CNLCP ..................................................................... 14 Peggy Neilson, BSN, RN, CNLCP, MSCC .............................................................................................. 15 Kathleen Phillips, RN, BSN, MSc Nsg Education, LNC, CNLCP, CM.................................................... 15 Evelyn G. Robert, BSN, RN, CCM, CRP, CLCP, MSCC .......................................................................... 15 Jan Roughan, BSN, RN, PHN, CRRN, CCM, CNLCP ............................................................................. 16 Nadene Taniguchi, BSN, RN, CCM, CNLCP, PAHM............................................................................. 16 Introduction ................................................................................................................................................ 17 Chapter 1 Amputation................................................................................................................................ 21 Introduction ............................................................................................................................................ 21 Bilateral upper extremity amputation, Ms. Doe ................................................................................... 23 Below the knee amputation with revision, Mr. Affleck ...................................................................... 106 Amputation Resources ......................................................................................................................... 142 Chapter 2 Brain Injury .............................................................................................................................. 147 Introduction .......................................................................................................................................... 147 Acquired brain injury, Kathy Doe ........................................................................................................ 149 Persistent vegetative state, Charlie Brown ......................................................................................... 162 Traumatic brain injury, Mary Doe ....................................................................................................... 180 Traumatic brain injury, Susan Smith ................................................................................................... 192

4 | Samples for Success Brain Injury Resources ......................................................................................................................... 236 Chapter 3 Burn.......................................................................................................................................... 245 Introduction .......................................................................................................................................... 245 Burn secondary to MVA, Robert Redford............................................................................................ 247 Burn secondary to home explosion and fire, Mary Doe ..................................................................... 290 Burn Resources ..................................................................................................................................... 335 Chapter 4 Cerebral Palsy .......................................................................................................................... 339 Introduction .......................................................................................................................................... 339 Cerebral palsy, Ruby Rose .................................................................................................................... 341 Cerebral Palsy, Penelope Cruz ............................................................................................................. 377 Cerebral Palsy/Jack Jones .................................................................................................................... 536 Cerebral Palsy Resources ..................................................................................................................... 588 Chapter 5 Elder Care................................................................................................................................. 591 Introduction .......................................................................................................................................... 591 Traumatic brain injury in 61-year-old secondary to MVA, Mrs. Jane Doe ......................................... 593 Hemiplegia in a 75-year-old male after spinal surgery, Mr. Smith .................................................... 627 Spinal cord injury in 81-year-old female, Jenny Lynn ......................................................................... 749 Elder Care Resources ............................................................................................................................ 761 Chapter 6 Pediatrics ................................................................................................................................. 763 Introduction .......................................................................................................................................... 763 Birth injury resulting in cerebellar infarctions, Shirley Template....................................................... 765 Three year old with Down syndrome, Johnny Doe ............................................................................. 801 Three-year-old with renal damage, Sally Roan ................................................................................... 816 Pediatric Resources .............................................................................................................................. 829 Chapter 7 Spinal Cord Injury .................................................................................................................... 833 Introduction .......................................................................................................................................... 833 C2 Spinal cord injury, Samantha Sample ............................................................................................. 837 T12 Spinal cord injury from MVA, Matthew McConaughey ............................................................... 876 T6 Spinal cord injury, Mr. Sanders ....................................................................................................... 924 Spinal Cord Resources .......................................................................................................................... 983

|5 Chapter 8 Transplant ................................................................................................................................ 987 Introduction .......................................................................................................................................... 987 Lung transplant, Jane Doe .................................................................................................................... 989 Heart and kidney transplant, Ms. Nightingale .................................................................................. 1001 Heart transplant, Jane Doe ................................................................................................................ 1100 Transplant Resources ......................................................................................................................... 1115 Chapter 9 Vision Loss ............................................................................................................................. 1117 Introduction ........................................................................................................................................ 1117 Retinoblastoma, Dan Aykroyd ........................................................................................................... 1119 Cortical blindness, Minnie Mouse ..................................................................................................... 1141 Vision Resources................................................................................................................................. 1163 Chapter 10 Creating Professional Curriculum Vitae.............................................................................. 1165 Resources............................................................................................................................................ 1256 Bibliography............................................................................................................................................ 1259 Appendix................................................................................................................................................. 1261 Life Care Planning Educational Courses............................................................................................. 1261 Life Care Planning Certifications ........................................................................................................ 1261 Life Care Planning Organizations ....................................................................................................... 1261 Advertised Life Care Planning Software ............................................................................................ 1261

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Preface My life care planning career started more than a decade ago when I began to get requests from insurance adjusters looking to establish costs for future medical treatment in workers’ compensation claims. At this time I didn’t even know the practice of life care planning existed.

By 2005, I had left a national case management firm and started my own nurse consulting company. My former manager with the same national firm found herself looking for work after a corporate downsize. She started over as a life care planner and quickly landed work on a large toxic tort case. Meanwhile, I was struggling as a legal nurse consultant and getting very few cases, which consisted mostly of workers’ compensation claims. Attorneys were primarily interested in bedside nursing experts, expecting testimony in various medical malpractice and medical negligence cases. Few knew the value of a behind-the-scenes nurse consultant. When sharing my frustrations with my former manager, she encouraged me to pursue life care planning. That was the first time I ever heard the term. I had an immediate desire to learn more.

After conducting some initial research, I realized that completing a formalized educational course in nurse life care planning was the most appropriate. I spent two weeks in an onsite program to learn nurse life care planning and Medicare Set-Aside allocations. A few months later I went to Memphis to take the Certified Nurse Life Care Planner (CNLCP®) examination.

After passing my certification I had a wonderful opportunity to be mentored by an experienced nurse life care planner who had been working in the field for several years.

The excitement of landing my first life care plan soon turned to panic when I realized the huge gap between the necessary assessment activities and research and the logistics of

actually creating the plan. I was fortunate to have my mentor to talk me off of the ledge; helping me put one foot in front of the other, step by step, until I placed that first plan in the attorney’s hands. I felt blessed and was appreciative, realizing that not every new life care planner had a mentor to call on.

My active involvement with the two major life care planning associations gives me the opportunity to speak with numerous new life care planners who share similar stories of nearparalyzing panic. There seems to be a great divide between our knowledge of disease processes, treatments, medications, caregiving recommendations, and the actual process of developing the life care plan. We work to land that first case then suddenly become confused or lose confidence in the next steps; putting pen to paper and developing the plan. It’s suddenly the furthest thing from our comfort area.

After completing nearly 100 plans, I’ve concluded that having a sample plan in front of me reduced my panic level because it confirmed that I was on the right track; my critical thinking wheels were greased and ready to roll. A sample plan’s recommendation may lead me to determine if a similar recommendation would be appropriate for my case. Or it might make me think of something completely unrelated, but yet pertinent to my plan.

This epiphany was the catalyst for developing this book: To give you resources to grease the wheels of your mind, to give you format and structure, and to simply spark ideas for research leads. There is no one “perfect” or “right” answer in life care planning. Every plan and every individual is unique. The final work is a product of one’s professional and expert opinion based on the best information available.

8 | Samples for Success This book isn’t meant to educate the reader on how to write a plan. It’s not a text to teach anatomy and physiology or disease progression.

It’s not intended to provide you with the only way to write a plan, or even the best way.

Rather, it’s a collection of plans from practicing life care planners, each with a different scope of practice, years of experience, and even from different parts of the world. Each contributor has agreed to provide glimpses into their life care plan development process. They also share some experiences with particular plans – positive, negative, and downright terrifying.

These aren’t necessarily the authors’ best plans. Some of these plans were associated with cases in which an award was provided; others were not. Whether the plan was good, bad, or otherwise may have had absolutely no bearing on the case outcome.

In every chapter’s introduction, I list key things to consider about the injury, disease process or associated litigation to empower the reader facing a similar experience. At the end of each chapter the reader will find numerous useful resources for plan development. Remembering that there is no right or wrong plan, readers will notice contributions vary in format, structure, layout, and language. The reader will find the terms patient, client, and evaluee used interchangeably. These terms are all used to

delineate the person for whom the plan was intended. As you will see, the life care plan and the planner both evolve over time as the result of testimony experiences, research, and professional development.

Full curricula vitae for all contributing life care planners are included in Chapter 10. Readers will again notice differences in layout, form, and language, and may find elements to incorporate into their own professional life care planning practices. The contributors welcome contact from any readers who need to locate experienced life care planners for potential mentoring, expert work, or further questions.

I hope you enjoy this first edition of Samples for Success: Life Care Plans by Practicing Life Care Planners and value the contributors who have helped make this book a reality. This book is meant to be a resource for new and experienced life care planners faced with writing a plan for an injury or illness that is less familiar.

Please provide feedback and help us to improve future editions. I also welcome hearing about your own struggles and successes. Here’s to no more ledge walking! Enjoy!

Victoria Powell

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About the Author Victoria Powell, RN, CCM, LNCC, CNLCP, CLCP, MSCC, CBIS, CEASII is a registered nurse with more than 20 years of professional nursing experience, primarily in neurology and orthopedics. She is the founder and President of VP Medical Consulting in central Little Rock AR, an independently owned and operated corporation providing a range of services to address future medical and non-medical needs of those with catastrophic injury/illness while projecting and documenting their associated costs. Ms. Powell provides expert testimony in the areas of life care planning, medical cost projections and litigated matters regarding worker’s compensation cases.

Ms. Powell develops life care plans for both plaintiff and defense with an emphasis on amputation and brain injuries. She has provided case management and life care planning services to individuals with amputations, including bilateral limb loss, quad limb loss, and infants as young as 18 months; spinal cord injuries, traumatic and acquired brain injuries, chronic pain and complex regional pain syndrome, birth defects, cerebral palsy, and many complex neurologic and orthopedic disorders.

Ms. Powell has been providing nursing education and consulting services for over 15 years. She has been an active member of the American Association of Nurse Life Care Planners (AANLCP®) since 2007, initially serving on the editorial committee for the AANLCP® Journal of Nurse Life Care Planning from 2007 until 2013 and currently as President of the Association. She has also been active with the AANLCP® Conference and Marketing Committees. She continues to peer-review articles as time permits.

Ms. Powell is an active member of the American Association of Legal Nurse Consultants, Case Management Society of America, International Academy of Rehabilitation Professionals; International Academy of Life Care Planners, National Alliance of Medicare Set Aside Professionals, and is a lifetime Hall of Fame Recipient for her contributions to the National Nurses in Business Association.

In addition to her work with AANLCP®, Ms. Powell has a lifelong dedication to learning. She holds specialty certifications in case management, legal nurse consulting, life care planning, Medicare set aside, ergonomic assessments, and brain injury. She has been published in numerous professional journals, has authored and contributed to textbooks in the field, and served as an editor for the twovolume Nursing Malpractice. Ms. Powell is a nationally-recognized speaker and regularly presents on a variety of medical-legal, nursing, and insurance industry-related subjects. She is an adjunct faculty member of the University of Florida’s Forensic Science for Nurses course. Interested parties may contact Powell via the web at www.vp-medical.com, by LinkedIn, or by phone at (501) 778-3378.

Within this book, Powell contributed a few of her own life care plan samples for chapters relating to amputation, elder care and vision loss.

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About the Contributors Kathy Allison, MS, PT, CLCP Transplant Kathie Allison, PT, MS, CLCP is a certified life care planner. She is a physical therapist with 41 years of experience in the field of rehabilitation, including seven years in health care management. She taught physical therapy at the University of Kansas from 1979 – 1986 and in 1993. Allison holds her BS in physical therapy from KU in 1972. She received her MS in perceptual motor development from KU in 1979. She has owned her own business since 1993, providing life care plans to attorneys and for the self-insured industry. Her first life care plan, for an individual undergoing organ transplant, was completed in 2001. She has completed over 75 life care plans for transplant clients requiring lung, liver, kidney, heart and/or multiple organ transplants.

Allison has participated in panel discussion regarding the unique contributions of physical therapist in life care planning and CLE for attorneys on establishing damages in catastrophic injury. She has served the physical therapy community at both local and state levels.

Barbara Bate, RN-BC, CCM, CRRN, CNLCP, LNCC, MSCC Brain injury Barbara Bate is president and owner of Northeast Life Care Planning, Inc., a national company providing medical case management, medical file reviews, Medicare set-asides, life care plan development and review, and medical cost projections. Barbara has over thirty years’ experience as a registered nurse and holds certifications in nurse life care planning, legal nurse consulting, rehabilitation nursing, case management, and Medicare set-aside consulting. She has provided medical case management services for patients with traumatic brain injury, spinal cord injury, amputations, and orthopedic injuries for the past 19 years in addition to clinical work experience in the operating room, recovery room, pediatrics and obstetrics. Her life care planning experience includes working with individuals diagnosed with multiple trauma, chronic pain, spinal cord injury, brain injury, birth injuries, burns, amputations, and blindness.

Ms. Bate has been an active member of the American Association of Nurse Life Care Planners (AANLCP®) since 2004 serving as President in 2010. Her initial involvement with the association was with the AANLCP® Educational Committee and the Editorial Board for the AANLCP® Journal of Nurse Life Care Planning. She was co-editor for the 2011 Spring Edition of the Journal and continues to peer-review articles prior to publication as time allows. In 2012, she joined the CNLCP® Certification Board.

She is currently a member of the Case Management Society of America (CMSA) and New England (CMSA-NE), the American Association of Legal Nurse Consultants (AALNC), the American Nurses Association (ANA), and the Association of Rehabilitation Nurses (ARN). She is a charter member of the National Alliance of Medicare Set-Aside Professionals (NAMSAP) and a current member of NAMSAP’s Board of Directors (2009-present).

12 | Samples for Success Ms. Bate has been published and has presented at several conferences geared towards the medicallegal and insurance industry. She lives in Holden, ME and can be reached at (877) 843-5729, bbate@nlcp.net, or www.nlcp.net.

Cynthia Bourbeau, RN, CRRN, CCM, CNLCP Cerebral palsy Cynthia Bourbeau is a nurse specialist who has been a Massachusetts registered nurse for 34 years. She has worked as a certified rehabilitation nurse case manager, with the focus of practice in rehabilitation from catastrophic injuries and illness. In 2001 she became certified as a life care planner and formed Medical and Life Care Consulting Services, LLC (MLCC). MLCC specializes in providing medical case management, medical cost projections and life care planning for spinal cord injury, burns, traumatic brain injury, amputations, degloving/crushing injuries, pain syndromes, birth injuries, major medical illness and orthopedic injury. She has been an active member of the American Association of Nurse Life Care Planners (AANLCP®) since 2001 and is presently a Board Member of the CNLCP® Certification Board.

Alisa Dayanim, RN, MSN, CRRN, CLCP, CNLCP Elder care, Pediatrics & Transplant Alisa Dayanim received a Bachelor’s Degree in Nursing from the University of Maryland in 1985 and a Master’s in Nursing from Thomas Jefferson University in Philadelphia in 1997. She holds certifications in rehabilitation nursing and life care planning.

Ms. Dayanim has over twenty-five years’ experience as a registered nurse, with rehabilitation of patients in acute care, outpatient and home based settings. Special interests include care of individuals with spinal cord injuries, traumatic brain injuries, amputations and multi trauma. At Balacare Nursing Solutions, she provides case management services for catastrophically injured adults and children. She has been preparing life care plans since 2006 and has testified in many trials and depositions. Her life care planning experience includes working with individuals diagnosed with spinal cord injury, amputations, multiple trauma, chronic pain, brain injury, burns, birth injuries and transplant. Ms. Dayanium is currently a member of the Association of Rehabilitation Nurses, the American Association of Nurse Life Care Planners, and the International Academy of Life Care Planners. She can be reached at (610) 664-8760, alisa@balacare.com.

Shelene Giles, MS, BSN, BA, RN, CRC, CNLCP, MSCC, LNCC Burn & Spinal cord injury Over twenty years ago, Shelene Giles began her career in assisting those with disabilities. Her attention began to shift more toward catastrophic cases and understanding the effect as well as the life changing events of the injury/illness. Through the years, she began to understand the impact of nurses in the litigation settlement process. She streamlined her experience and knowledge and now focuses on determining future cost of care in catastrophic cases. For the past several years, her focus has been on

| 13 life care plans for catastrophic burn survivors. She is the only nurse life care planner in the nation with a specialty in catastrophic burn cases.

Ms. Giles’ education includes a BA in Business Administration & Counseling Psychology, an MS in Rehabilitation Counseling, and BS in Nursing. She is certified in rehabilitation counseling, life care planning, Medicare set-asides, and legal nurse consulting.

Ms. Giles is the owner of FIG Services, Inc., an independent corporation that provides services to determine and understand future cost of care and coordinate care for the elderly and those with catastrophic medical conditions. Since 1989, she has been involved in medical and vocational case management, legal nurse consulting, ergonomic consulting, work injury prevention programs, return to work programs, medical file reviews, medical cost projection services, life care plan services, Medicare set-aside allocations, settlement consulting, and serving as an expert witness. FIG is also an internationally recognized educational provider in the field of nurse life care planning and Medicare SetAsides.

She has authored articles and provides education and mentorship concerning nurse life care planning and Medicare set-asides. For the past 10 years, Ms. Giles has spoken nationally among nurses, medical providers, insurance carriers, employers, plaintiff and defense attorneys, and families regarding issues surrounding catastrophic injuries/illnesses. She has been involved in many professional associations, including as President in 2008 of the American Association of Nurse Life Care Planners.

Wendie Howland, MN, RN-BC, CRRN, CCM, CNLCP, LNCP-C, LNCC Burn & Elder care Wendie A. Howland MN, RN-BC, CRRN, CCM, CNLCP, LNCP-C, LNCC is a graduate of Boston University, Boston MA (Bachelor of Science, Nursing), and the University of Washington, Seattle WA (Master in Nursing, Physiological/Critical Care). She is certified in case management (CCM, RN-BC), rehabilitation nursing (CRRN), life care planning (CNLCP, LNCP-C), and legal nurse consulting (LNCC).

Following work as a critical care clinical specialist and nursing school faculty and twenty years in worker’s compensation field case management, she founded Howland Health Consulting, Inc., Cape Cod MA, specializing in catastrophic case management and life care planning for catastrophic and highexpense chronic conditions, and helping attorneys determine damages in medical-legal cases nationwide. She works for defense and plaintiff firms, primary and reinsurance carriers in worker's compensation and liability, and structured settlement attorneys and financial planners.

Ms. Howland is a member of the American Association of Nurse Life Care Planners, serving as the Editor of the Journal of Nurse Life Care Planning and the Core Curriculum for Nurse Life Care Planning. She is a long-time member of the Case Management Society of America. She is a member of the American Association of Nurse Life Care Planners, Case Management Society of America, and the American Association of Legal Nurse Consultants, serving as the editor of the Journal of Legal Nurse Consulting.

She is a member of the NANDA-International Education and Research Committee and is a contributor to The Nursing Diagnosis Handbook, 11th ed., (Ackley and Ladwig). She has published and spoken to many national and regional conferences, webinars, and other online venues on life care planning, legal

14 | Samples for Success nursing, and related topics, and assists professional and academic writers with editing services. Howland can be contacted via LinkedIn or at whowland@howlandhealthconsulting.com, (508) 564-9556.

Alex Karras, OTR, CRC, CCM, MSCC, CLCP Amputation & Cerebral palsy Mr. Karras is a registered occupational therapist with the American Occupational Therapy Association.

He is a member of the International Association of Rehabilitation Professionals, Diplomate and lifelong member of the American Board of Disability Analysts. He is a member of the National Alliance of Medicare Set–Aside Professionals, and holds certifications in rehabilitation counseling and case management. He serves on the Board of Directors of the International Commission on Healthcare Certification Life Care Planning. Since 1976, he has provided therapeutic and counseling services to individuals with severe and catastrophic disabilities. Mr. Karras has experience in providing therapeutic and case management services to individuals suffering from mental health and developmental disabilities both in the clinical and community based residential settings as a counselor in a group home, to establish life training skills, assist the severely and profoundly developmentally delayed to become part of the community socially and return to either sheltered or competitive employment.

Mr. Karras has provided rehabilitation counseling, case management and life care planning services to individuals with spinal cord injuries, traumatic brain injuries, acquired brain injuries, amputations, patients with chronic pain and complex regional pain syndrome, birth defects, cerebral palsy, and complex neurologic and orthopedic disorders. Mr. Karras provides expert testimony in the areas of life care planning, medical cost projections, and worker’s compensation. Over his career, he has consulted with insurance carriers and large self-insureds throughout the country on managing and coordinating medical care services and projecting medical costs for severe and catastrophic injuries. He has developed training programs and has lectured to the insurance industry in assessing the severity of catastrophic injuries and determining the lifelong care requirements and costs involved in providing services to the catastrophic injured for reserve and settlement purposes. He has lectured in the areas of the care and management of spinal cord injuries, traumatic brain injury, amputations, chronic pain and injured parties with severely involved orthopedic and neurologic disorders.

Mr. Karras may be contacted via LinkedIn or at (215) 530–5041.

Kimberly Kushner MSN, BSN, RN, CPNP, CLCP, CNLCP Pediatrics Kimberly Kushner received her Bachelor’s Degree in Nursing from the Pennsylvania State University in 1997 and a Master’s Degree in Nursing from Emory University in 2000. Ms. Kushner achieved certification in Life Care Planning (CLCP) and Nurse Life Care Planning (CNCLP) in 2011.

Ms. Kushner has more than 10 years of nursing experience and is a certified pediatric nurse practitioner.

Her clinical experience includes critical care, burn, cardiac, and oncologic and hematologic conditions.

Her particular expertise and interest is with chronic illness and pain management in the pediatric client.

| 15 Ms. Kushner has worked with BalaCare Nursing Solutions for more than four years and is a member of the American Association of Nurse Life Care Planners and the International Academy of Life Care Planners. In addition to her work in life care planning and case management, she continues to work as a camp nurse for children with cancer every summer.

Peggy Neilson, BSN, RN, CNLCP, MSCC Brain injury & Spinal cord injury Peggie Nielson is a Registered Nurse with certifications in Life Care Planning and Medicare Set-Aside Allocations at ExamWorks Clinical Solutions. She received her BSN from Marshall University. After her fifteen-year career working in the hospital and office setting, Ms. Nielson decided it was time for a change and completed nurse life care planning certification in 2007. She completed her Medicare Set Aside allocation credential in 2011. She is active in the American Association of Nurse Life Care Planning, serving on the Executive Board as Treasurer from 2011 to 2013. Ms. Nielson was also a contributor to the American Association Nurse Life Care Planning Core Curriculum, published in 2013.

Kathleen Phillips, RN, BSN, MSc Nsg Education, LNC, CNLCP, CM Kathleen Phillips has been a Canadian Registered Nurse for over 40 years. She received a Master's of Science in Nursing Education from the University of Edinburgh, UK in 1987. Her nursing career has included working in critical care, teaching nursing at a college level, nursing management in the hospital setting and for the past 18 years administering a self-owned community home care agency. In 2004 she began the journey to include legal nurse consulting and life care planning to her resume. She was certified as a Nurse Life Care Planner in 2011 and has worked exclusively in this field since retiring from her home care business in 2013.

Kathleen has raised two children as a single mother and is now a proud grandmother to one little boy.

Her interests including traveling, quilting, hiking, reading, golfing and spending as much time at her summer condo as possible.

Evelyn G. Robert, BSN, RN, CCM, CRP, CLCP, MSCC Ms. Evelyn Robert serves as the Executive Director of the International Commission on Health Care Certification (ICHCC). Her primary role is to oversee the various Board Committees and to coordinate the monthly Commissioner conferences. Ms. Robert is responsible for assembling and overseeing the Ethical Review Board when complaints are forwarded to the ICHCC for review. She obtained her Bachelors of Science in Nursing in 1978 from Molloy College, Rockville Center, New York. Her hospital experience includes medical surgical and step down surgical ICU. After leaving the hospital in the late 1980's she assisted in the development and implementation of a Multidisciplinary Medical Clinic under Medicaid for a Residential Drug Rehabilitation program located in Long Island. Over the past ten years she developed and implemented a Return to Work Program for a local shipyard and provided medical consulting services for local municipalities in their liability department. Ms. Robert has provided onsite case management and received training for Critical Incident Stress Debriefing to assist employers and

16 | Samples for Success employees with traumatic events. She found herself back home in New York following the September 11th tragedy, assisting all levels of management and employees with the loss of co-workers, as well as families with the loss of their loved ones. Currently, Ms. Robert is president of Medical Dynamics Associates, her private consulting firm that specializes in case management services and life care planning service delivery. She is a board member for Hope U Foundation, a non for profit agency helping emancipated young adults with housing, life skills and vocational training. Ms. Robert is bilingual, with Greek as her second language, and currently resides in Virginia Beach with her husband.

Jan Roughan, BSN, RN, PHN, CRRN, CCM, CNLCP Pediatric brain injury & Vision loss Jan Roughan is a rehabilitation nurse specialist, case manager, life care planner, and expert witness. Her company, Roughan & Associates at LINC, Inc., founded in 1987, provides case management and medical/legal consulting, coordinates patient care, develops life care plans, and offers consultative services to both the defense and plaintiff bar on simple and complex cases ranging from infancy to the senior population. Roughan & Associates nurse specialists work with many conditions, including neurological injuries (brain and spinal cord injury), burns, orthopedic injuries, amputation, chronic pain, post traumatic stress disorder, and others. Ms. Roughan is a current member of the American Association of Nurse Life Care Planners and will serve as Chair of the Nurse Life Care Planners Certification Board for 2015. She can be reached via her website at www.linc.biz.

Nadene Taniguchi, BSN, RN, CCM, CNLCP, PAHM Brain injury Nadene R. Taniguchi is a nurse life care planner at BalaCare Nursing Solutions. She has a vast background in healthcare, including over 30 years’ experience in care coordination, utilization review, risk management and the revenue cycle, and now, life care planning. She has spearheaded projects with healthcare professionals to develop improved emergency department through enhanced patient safety and improved patient satisfaction.

Before joining BalaCare Nursing Solutions, Ms. Taniguchi was the Administrative Director, Care Coordination for a major teaching hospital in New Jersey as well as the Director of Revenue Integrity with a focus on compliance and revenue capture. She is a registered nurse, Certified Case Manager (CCM), Certified Nurse Life Care Planner (CNLCP), and Professional with the Academy of Healthcare Management (PAHM).

At BalaCare Nursing Solutions, Ms. Taniguchi enjoys the privilege of being mentored by Mona Yudkoff, RN and working with a team of professionals that pride themselves in producing the most comprehensive product in the industry.

Ms. Taniguchi received her BSN from St. Joseph’s College, in Standish, Maine and is currently completing a master’s degree in Nursing at St. Joseph’s College. In her words, “Nursing has been the most fulfilling profession I could have ever hoped for. From my early clinical days in trauma to my current career as a life care planner, it has been a true joy.”

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Introduction This book is presented in nine chapters focusing on particular disabilities. Each chapter includes an overview of the disability and pertinent life care planning considerations. The contributors have provided examples of their work as well as information specific to the related legal cases.

Appendices are also included to provide information on life care planning associations and educational courses.

This book was developed as an adjunct resource for preparing life care plans. There are few resources available for novice planners or planners who work on cases outside their usual and customary practices. The reader will find resource sections at the conclusion of each chapter which include additional research and reference resources to assist in developing credible and sound life care plans.

The life care planner should not copy the plan contents. They are provided as a reference for formatting, grid layout, references, real-life experiences, and direction for critical thinking efforts. Copying a plan will constitute copyright infringement and will eliminate all credibility of the plan in court.

What is a Life Care Plan?

“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 cost for individuals who have experienced catastrophic injury or have chronic health care needs (IALCP 2009).”

The American Association of Nurse Life Care Planners (AANLCP®) defines nurse life care planning as: … the specialty practice in which the nurse life care planner utilizes the nursing process in the collection and analysis of comprehensive, client specific data in the preparation of a dynamic document. This document provides an organized, concise plan that estimates reasonable and necessary (and reasonably certain to be necessary) current and future healthcare needs with the associated costs and frequencies of goods and services. The nurse life care plan is developed for individuals who have experienced an injury or have chronic healthcare issues. Nurse life care planners function within their individual professional scope of practice and, when applicable, incorporate opinions arrived upon collaboratively with various health professionals. The nurse life care plan is considered a flexible document and is evaluated and updated as needed.

(AANLCP®, 2008) Most life care planners enter this field by attending an educational course. Due to the complexity of needs we see as life care planners, a structured introduction to this specialty practice is highly recommended.

Universities, colleges, for-profit, and not-forprofit organizations offer life care planning education. Before committing to any program, consider the instructors’ qualifications carefully, to be sure that the program includes a solid knowledge base taught by those experienced in the field.

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5 Elder Care Introduction Elder Care Plans included: 1) Mrs. Jane Doe – Traumatic brain injury secondary to motor vehicle accident 2) Mr. Smith – Hemiplegia 3) Jenny Lynn – Spinal Cord Injury

American population.

Consider implications for life care planning:

these

Two-thirds of older Americans have multiple chronic conditions (State of Aging, 2013).

People living with one or more chronic conditions will often experience a diminished quality of life. The chance of having a disability rises with age, approaching 75% for people aged 80 or older.

Elders with catastrophic injuries often have comorbidities. However, just because someone is older it doesn’t mean they are disabled. The life care planner must work with the physician to identify and quantify underlying age-related or premorbid conditions. For example, if the life care planner is working with a patient who has a degenerative spine condition and then suffers a back injury it is important to document the change in treatment types, treatment frequency, subjective reports, and associated diagnostics.

Hypertension is a major risk for cardiovascular disease. Of the 67 million American’s with high blood pressure, more than half do not have it under control (State of Aging, 2013).

State of Aging and Health in America 2013 reports the growth in number of older adults is unprecedented in US history. The baby boomers’ long life spans will double the population of those aged 65 or older during the next 25 years in the U.S. By 2030, older adults will account for roughly 20% of the total

About 35% of adults aged 65 or older have some type of mental health problems (State of Aging, 2013). Physically unhealthy older adults have the highest rates of poor physical health and activity limitations

Chronic conditions can affect ability to perform essential activities of daily living. Impaired mobility is associated with health problems such as depression, cardiovascular disease, and injury. Impaired mobility can also limit one’s access to goods and services or limit contact with others.

592 | Samples for Success Obesity is on the rise among older Americans.

Obesity is a major cause of preventable disease and premature death (Aging Stats, 2012).

Things to Consider:  Impaired mobility is associated with various adverse health conditions  Those 65 and older have the lowest rate of proficiency and the largest percentage of below-basic literacy  Sensorineural changes cause sleeping patterns, vision deficits, hearing loss  Qualify and quantify premorbid conditions and exacerbations

The nature of these conditions leads to a need for multiple health care specialists, treatment regimens, and prescription medications.

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Traumatic brain injury in 61-year-old secondary to MVA, Mrs. Jane Doe Ms. Howland was retained by the plaintiff to develop a life care plan for a woman in her sixties who had been hit by a van in a crosswalk on a dark and rainy night, sustaining multiple orthopedic injuries after being thrown some distance. More significantly, she sustained extensive skull fractures with brain injury causing hemiplegia, spasticity, and hydrocephaly treated with a ventriculoperitoneal shunt. Her later medical records included a report that her hemiplegia was caused by an aneurysm, but Ms. Howland traced this back to an erroneous discharge note from a resident who apparently misread an operative report of aneurysm, which was an incidental finding during one of her shunt revisions. It was clipped without incident and had never been symptomatic, and was certainly not the cause of her considerable neurological deficits. This detail was critical to the plaintiff’s case.

Ms. Doe was nonverbal in any language due to the brain injury. Her husband did not speak English; most communication went through the couple’s daughter. The family did not clearly understand the extent of her injury and Ms. Howland felt they had a long way to go to accept her very poor chances for functional recovery. However, her family’s main goal was to bring her home so she could be present for the family life that was so important in their culture, even if she were disabled. They identified incontinence and her inability to swallow food as major sources of sadness. Their home was very old, very small, situated on a very small lot, and completely unsuitable for any modifications, as shown in the pictures in the plan. Ms. Howland worked with several contractors and real estate agents in their area to get information on purchasing an accessible home vs. purchasing another house and modifying it for safety and accessibility.

Interestingly, the educational level Ms. Doe achieved in her home country before coming to the US was never mentioned in her record. Ms. Howland was able to convince the attorney the patient needed a neuropsychological evaluation with a qualified medical translator present to quantify her deficits; knowing these were critical in justifying many of the recommendations in the plan. He identified devastating cognitive and functional losses that he expected to be permanent.

Although the family wanted a modified van, Ms. Howland did not feel it would be safe to include a van with lift, because the patient’s husband (the driver) was not medically safe to drive. Transportation was provided in the plan with a car service for medical appointments and a number of on-call visits for personal use, e.g., visits to family, outings, etc. However, Ms. Howland included the cost of a van in an addendum because the husband requested it of the attorney, saying the son-in-law could drive it.

The attorney was very interested in the concept of the nursing process as a life care planning methodology. At the time of publication the case outcome is unknown and awaiting mediation. The patient is still in the skilled nursing facility; with no functional improvement several years post injury.

Ms. Howland incorporates pictures and other graphics to get the attention of the reader in a way that text alone does not, and helps illustrate the severity of the injury. This helps the attorney and others understand the rationales for her recommendations. She also recommends using specific vendors and CPT codes in her tables; as a result, opposing counsel rarely challenges her to justify her information sources in deposition.

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Howland Health Consulting, Inc.

Wendie A. Howland MN RN-BC CRRN CCM CNLCP LNCC Legal Nurse Consulting, Life Care Planning Case Management Services

Life Care Plan Report Date: Name: Jane Doe Date of Birth: Date of Injury: 11/1/20xx Client Name: Law Offices of Medical Diagnoses: Traumatic brain injury with right skull fracture and intracranial hemorrhage; bimalleolar right ankle fracture; right shoulder fracture/dislocation. Severe posttraumatic cognitive deficits, functional deficits, spasticity, and parkinsonism.

866-604-9055



fax 915-990-1367



www.howlandhealthconsulting.com

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INTRODUCTION

2 Jane Doe Date

A Life Care Plan is a tool for estimating medical and non-medical needs of a person with a catastrophic injury or chronic illness over an estimated life span. It is a dynamic document based upon published standards of practice, comprehensive assessment, data analysis and research. A Plan may include medical needs and costs, future projections, and a vocational assessment. The contents may be comprehensive or modified, based on the needs of the party making the request.

This Life Care Plan is not generalized for traumatic brain injury and common sequelae; it addresses the author’s best nursing assessment of Mrs. Doe’s specific health status and care needs.

The assessment includes collecting subjective and objective data from observations, examinations, interviews, and written records. The Plan follows the nursing process to develop a goaloriented plan of care as defined in the Nurse Practice Act. All prices included in the Plan are based on today’s dollars and are obtained from suppliers, facilities, pharmacies, vendors, and providers. Shipping is included in costs if the product is unavailable in the local area. Equipment maintenance varies with individual needs and frequency of equipment use. Costs do not reflect inflationary trends of the health care industry. Allowances for inflation and any medical care cost trends should be determined by a qualified forensic economist.

This Plan cannot guarantee absence of errors and omissions, nor can it guarantee optimal outcomes with suggested interventions. The plan provides a guideline for optimizing Mrs. Doe’s care to prevent possible complications. Implementation of this plan cannot guarantee the absence of complications, predict with certainty Mrs. Doe’s future needs, or guarantee all costs related to her future medical and care needs. The author reserves the right to modify it if new information is received.

The Life Care Plan should be reviewed and updated by the author every 6 to 12 months. It does not include a vocational assessment. A qualified vocational counselor should be consulted for this purpose if desired. Finally, the Plan includes recommendations for medical case management services to coordinate cost-effective medical care and address recommended equipment needs.

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RECORDS REVIEWED

3 Jane Doe Date

Approximately 9000 pages of medical records and medical billing were received. All records received were reviewed.

Past History and Summary of Medical Care

Mrs. Doe is a 61-year-old woman who moved to this country from Germany with her husband and three children after the end of the Cold War there. She learned some English here, but primarily spoke German. She did not work outside the home, and raised her children and enjoyed caring for her grandchildren at the time of her injury.

Mrs. Doe sustained severe post-traumatic cognitive deficits, functional deficits, spasticity, and Parkinsonism after a brain injury sustained in a motor vehicle vs. pedestrian accident on October 1, 20xx. She also sustained a bimalleolar right ankle fracture and a right shoulder fracture/dislocation. Admission documentation noted that Mrs. Doe had no significant past medical or surgical history.

At the scene emergency medical services personnel noted that witness reported that she had lost consciousness. She opened her eyes spontaneously, made confused verbal responses, and obeyed commands. They noted severe right ankle deformity and right arm deformity. They gave her oxygen, applied a cervical collar to splint her neck, inserted an intravenous line, and transported her with monitoring to Medical Center Medical Center.

In the emergency room she was initially responsive with a Glasgow Coma Scale of 15; however, this deteriorated rapidly to 7 in the trauma bay. She ceased spontaneous movement of her left leg. Her pupils became pinpoint and fixed (unresponsive to light). She was intubated and placed on a ventilator. She was found to have a severe skull fracture extending from her right eyebrow area to the back left of her skull. She had bleeding in both sides of her brain, right worse than left, enough to shift her brain 8-10 mm off midline. She was taken to the operating room where the neurosurgeon removed a large part of her skull to decrease the pressure on her swollen brain and placed intracranial devices to monitor pressure in her brain; she wore a helmet to protect her brain until her preserved skull bone was replaced some weeks later. She also had her shoulder and ankle fractures reduced and splinted.

She was given medications to decrease the chances of pneumonia and seizures.

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4 Jane Doe Date

Repeat imaging the next day revealed worsening bleeding on the right and increased leftward midline shift with left hydrocephalus and mass effect upon the right ventricle. By November 6, 20xx the neurosurgeon noted decerebrate posturing of the left arm and decorticate posturing of the right arm. These are very abnormal reflexes that result from severe injury to the cereDecerebrate posturing (A) is caused by damage to

bral hemispheres, midbrain, and cerebellum /

the upper brain stem. In response to stimulus or

upper brain stem and the connections between

spontaneously, the arms extend stiffly and held turned in at the sides, with the wrists and fingers

them needed for control of motion and reflexes

tightly bent. The legs extend rigidly extended with

(illustration left). Damage to these areas cause

the feet pointing.

permanent spasticity, rigidity, and abnormal re-

Decorticate posturing (B) is caused by damage to

the brain connections that run from the cortex

flexes in response to stimulus. Extensive cerebral

(upper brain) through the brainstem to the spinal

hemisphere injury also causes severe cognitive

cord (“extrapyramidal”). In response to stimulus or

deficits.

Mrs. Doe had a tracheostomy for airway management and a feeding tube (PEG, percutaneous endoscopic gastrostomy) placed on November 11. She had abnormal pupil response to light on the right, indicating damage to the part of the brain that manages this reflex; this is a very basic brain function and indicates severe injury. Physicians recommended transfer to long-term care due to her poor prognosis for functional recovery.

Her family requested that she be transferred to an acute rehabilitation facility. At the time of transfer to ABC Rehabilitation Hospital in City ST on December 6, 20xx, her physician noted her condition including the following: • • • • • • • •

Injuries as noted previously Right craniotomy with skull piece removal, helmet on at all times Extensive bilateral hemorrhage and neuronal loss on repeat CT Central fevers (i.e., fevers caused by damaged temperature control center in brain) Glasgow Coma Scale low at 5 without change Some right leg focal seizure activity Tolerated tube feeding well Passy-Muir valve (speaking tracheostomy), some speech in native language

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The plan of care at ABC included the following goals:

5 Jane Doe Date

• All calories to be from regular diet taken orally • Speech independent • Problem solving and memory with minimum cues • To be continent of urine 90% of the time, 10% continent of bowel • Modified independence for bed mobility • Minimum assistance for transfers and household ambulation • Modified independence for orofacial hygiene • Minimum assistance for bathing and dressing • Psychological stability for significant functional improvement within 4-6 week stay Discharge was considered likely to be to home with 24-hour care or to a skilled nursing facility, due to the expected levels of permanent disability with an injury of this severity.

Mrs. Doe was a patient at ABC until December 29. During her stay she had varying periods of increased and decreased responsiveness. Her fractures were evaluated in late December; the shoulder fracture/dislocation was diagnosed with malunion; the orthopedic trauma service opined that they could intervene surgically if neurological recovery allowed. The ankle fracture was healed but in an abnormal position; air cast was recommended.

On December 29, 20xx she was sent to the Mercy General Hospital (MGH) Emergency Department for evaluation of markedly decreased alertness and right-sided rhythmic tremor. She was found to have low serum sodium, which would increase brain swelling; she was noted to have increased swelling at her hemicraniectomy site (site of removal of skull bone). She was also relatively hypothyroid and on hormone replacement for this. CT showed hydrocephalus (collection of fluid in the ventricles) and herniation of her brain through the hemicraniectomy site with no new hemorrhage. EEG showed no seizure activity related to the tremors but she was placed on an anti-seizure medication prophylactically.

Her serum sodium was corrected, her thyroid medication resumed; neither improved her presentation. She had a lumbar puncture to decompress her hydrocephalus. She continued to decline and was intubated for respiratory failure. Repeat CT showed a new hemorrhage in her ventricle and brain tissue with possible areas of evolving infarction (tissue death) and fluid in the areas around the ventricles (transependymal flow). There was an incidental finding of a small aneurysm in her right middle cerebral artery, with no associated bleeding from this. On December 28 she had an external drain placed in her ventricle.

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On January 13, 20xx she had a tracheostomy for respiratory control

6 Jane Doe Date

and support, aneurysm clipping, and bone flap replacement. By January 16 her mental status was improved. She was discharged from the ICU to the floor on January 22 after drain removal. As her ventricles appeared to have slightly increased in size, evaluation for ventriculoperitoneal (VP) shunt was recommended (drain from brain fluid collection to abdomen for decompression, illustration at right). She was transferred back to Medical Center for continued care.

At admission to Medical Center on January 30, 20xx, Mrs. Doe had the following findings: •

flaccid left arm

•

weak grasp with the right hand

•

no spontaneous leg movement

•

clonus (abnormal involuntary rhythmic contraction/relaxation), increased tone, and exaggerated reflexes in the right leg

•

ventricular size mildly dilated compared to January 24 study at MGH

The medical plan of care was for continued monitoring and VP shunt placement if worsening neurological exam or mental status correlated with increasing ventricular size. The shunt was placed on January 29, 20xx, with no complications.

Although she had had no significant neurological improvement while at Medical Center, she was accepted for admission to Major acute rehabilitation as she had a new tracheostomy diagnosis.

Acute rehabilitation criteria include the ability to participate in three to five hours of therapies per day.

On admission on February 7, 20xx, she was nonverbal. Her tracheostomy was capped, so she breathed through her mouth and nose. She was noted to have some autonomic dysfunction. i.e., changes in heart rate and blood pressure related to injury of the nerve system that controls these.

She had clonus in both arms. She required a tilt-in-space wheelchair with head rest (representative illustration, right), calf rests, foot supports, and headrest support because her spasticity caused her to extend (straighten) her trunk and hips, which would cause her to slide

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out of a regular chair.

7 Jane Doe Date

Physical therapy evaluation found that she was essentially unable to stand without maximal assistance of three persons, largely due to the spasticity and lack of motor control in her legs and trunk. Over the course of several weeks Mrs. Doe had periods of increased alertness and success in overcoming increased tone, alternating with periods of significant lethargy and exercise intolerance.

Speech-language pathology (SLP) performed a swallow evaluation and recommended moist ground solids with dentures if available (there are none and Mrs. Doe has no teeth), with advancement as indicated by tolerance. Feeding and hydration was given via PEG tube.

After three weeks in acute rehabilitation, Mrs. Doe had somewhat improved sitting tolerance but remained completely dependent for all functional activities of daily living, i.e., feeding, toileting (incontinent), dressing, bathing, grooming, and mobility. She was deemed appropriate for discharge to subacute rehabilitation for continued work with SLP to improve swallow safety. She was discharged to Legacy Hall East Building on February 28, 20xx.

At Legacy Hall her medications were adjusted to improve extrapyramidal symptoms and alertness (amantadine) and decrease spasticity (baclofen). She had restorative therapies to address range of motion, positioning, and skin condition. She began to be able to feed herself somewhat.

She had another two-to three-week period of increasing lethargy, decreased self-feeding, and increased spasticity. She was being treated for a UTI. On March 30, 20xx, she was sent to Medical Center for head CT and work-up to rule out shunt malfunction, repeat intracranial bleed, or other cause of neurological deterioration such as persistent urinary tract infection (UTI). It was noted that she “did not tolerate� a higher dose of baclofen, although the dose given had been in place for four weeks according to the Emergency Department physician’s note. He felt that progressive sleepiness would be unlikely to be an acute event, not characteristic of shunt malfunction.

On March 28, 2012 the physiatrist Dr. Washington noted that the neurosurgeons had ruled out shunt problems, there was no infectious condition found, and the appropriate placement for her would be longterm care, not acute or subacute rehabilitation given her present condition this long after her initial injury. He recommended return to Legacy Hall as there was a physiatrist on staff

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8 Jane Doe Date

there. The family refused to return her there; he recommended evaluating whether their concerns were specific to the facility or would apply to all skilled nursing facilities.

On March 29, 20xx the neurosurgery consult Dr. Adams discounted the “very modest” increase in baclofen as a cause for her presentation and recommended that it be resumed to treat her spasticity. The family refused this. Prognosis was that any further gains would be marginal at best and not greatly change her functional abilities. Recommendation was to return to a long-term care facility.

On March 30, 20xx, Mrs. Doe was admitted to Care Center Rehabilitation. The initial physical therapy and occupational therapy evaluations concluded that she was not appropriate for skilled therapy due to her unresponsiveness and inability to participate in the evaluation. Her admitting diagnoses were: • • • • •

traumatic brain injury post MVA G-tube recent UTI hypothyroid extrapyramidal movements (indicates damage to multiple parts of the neurological system that controls involuntary reflexes and movements and coordination, characteristic of parkinsonism) / spasticity

She was seen by Dr. Washington, physiatry, who noted she was familiar to him from her recent admission to Medical Center. He was asked to evaluate her for further recommendations. His assessment was “Severe TBI with mild to moderate spasticity, positive rigidity.

Level III - Localized Response: Total Assistance

• • • • • • • •

Demonstrates withdrawal or vocalization to painful stimuli.

Turns toward or away from auditory stimuli.

Blinks when strong light crosses visual field.

Follows moving object passed within visual field.

Responds to discomfort by pulling tubes or restraints.

Responds inconsistently to simple commands.

Responses directly related to type of stimulus.

May respond to some persons (especially family and friends) but not to others.

Rancho Los Amigos Cognitive Scale, Revised Levels of Cognitive Functioning Los Amigos Research and Educational Institute, 1990

Very low-functioning, approximately Rancho Los Amigos 3 (see above). No agitation. Hypoactive.

He opined that she appeared abulic1 as a result of her brain injury rather than depressed, so the medication she had been on for presumed depression was probably not indicated. He recom1

Abulia is characterized by difficulty initiating and maintaining purposeful movement, increased response time to questioning, passivity. In progressive dementia, it may affect feeding; the patient may not swallow food and may stop eating after consuming part of their meals, no longer having strong appetite.

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9 Jane Doe Date

mended resuming baclofen for spasticity, and adjusting her amantadine to provide peak effects during waking hours.

In early April Mrs. Doe had another period of decreased responsiveness and decreased oral in-

take. She was sent to the Medical Center Emergency Room for evaluation and admitted on April 7. Work-up was characterized as unremarkable: 24-hour EEG and CT were negative, with no seizure activity seen, and no fever. She gradually became more alert two days later. Neurosurgery made no recommendations. Neurology started her on Keppra, an anti-seizure medication, despite no correlation between motor symptoms and EEG. She was discharged back to the Care Center Rehabilitation on April 13.

She was re-evaluated by therapies and discharged after ten days for lack of ability to participate or progress. On April 25, 2012 SLP discharge evaluation noted, “Has achieved highest functional level. Continues to demonstrate oropharyngeal dysphagia and cognitive-linguistic deficits that impact her swallowing. Her dysphagia is best managed with puréed and nectar-thick diet and one-to-one assistance for any oral intake.” The physician note stated, “Is at baseline, will not walk again.”

On May 3 she was again sent to Medical Center at her family’s insistence for change in mental status and decreased appetite. No changes were identified. EEG and CT were unchanged. In follow up at return to Care Center, Dr. Washington again noted that in his opinion she was abulic, not depressed, and recommended reevaluating need for medications for depression. He recommended increasing amantadine (this recommendation was refused by the attending nurse practitioner) and increasing baclofen for spasticity. This was apparently ordered.

Dr. Washington saw her monthly. In July 20xx he noted that her increased muscle tone (tightness) and cogwheel rigidity2 were unchanged. He again recommended gradually increasing baclofen to 15 mg three times daily. He also recommended a trial of carbidopa/levodopa (Sinemet), a medication used in Parkinson’s disease and Parkinsonism, to attempt to treat spasticity and rigidity. He felt there was minimal to no role for continued physical therapy. Consult with neurologist resulted in weaning off Keppra.

2

This is a combination of rigidity and spasticity, characteristic of parkinsonism and related to damage in the parts of the brain related to coordinated movement. For a video illustration, see http://www.youtube.com/watch?v=uOtTPHy_plM 0:27 - 0:45

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Physical therapy re-evaluated Mrs. Doe on July 22, 20xx. Splints were requested for both knees to decrease contractures. The family requested a second physiatry opinion for rehabilitation po-

tential; however, it appears that Dr. Washington continued to see her. Splint for left knee was not initiated. Occupational therapy noted decreased hand range of motion and difficulty with hand splints reported by nursing. The splints were found to fit appropriately, although Mrs. Doe wiggles out of the left one whenever possible (see picture front page of this report to appreciate spastic contractures in the left hand; see also decerebrate posturing illustration).

An evaluation in August 20xx by State Geriatrics mentions “significant psychiatric history: PTSD when in Germany.” The source of this information was not noted. They recommended a neuropsychological evaluation. Family reported that they felt she had become more spastic since transferring to Care Center (note, this is normal progression for this kind of brain injury) and has not been maintaining or progressing in her rehabilitation. SLP noted increased verbalization and accuracy of responses, although she needed cuing to respond and often said, “I don’t know,” or “I don’t understand.”

Dr. Madison, physiatry colleague of Dr. Washington, saw Mrs. Doe on August 26, 20xx. He concurred with Sinemet recommendation; this was started, and tolerated well. Repeat MRI was ordered to check for recurrent hydrocephalus. No records of this or of changes in shunt or other related care are found in the records available for review.

FAMILY GOALS

Mrs. Lucy Lincoln is Mrs. Doe’s daughter. Her mother-in-law lived with her and her family after she developed Alzheimer’s and was unable to care for herself. At some point she became incontinent and unable to use the bathroom; this was when they had to place her in a care facility. According to Mr. Doe and Mrs. Lincoln, this is the main reason why their goal is that Mrs. Doe be able to use the bathroom independently, being able to transfer from her wheelchair to a commode or toilet. They feel that she was able to do this while she was at ABC, and they feel that she uses diapers at Care Center because it is more convenient for the staff; they feel she is aware of her need to use a toilet as evidenced by her utterances about this and the fact that she tries to get out of bed for this purpose. They would like to have some way of allowing her to use a toilet or bedside commode.

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11 Jane Doe Date

They also feel that when she refuses therapies the staff should find a way to have her do them anyway. They feel she should not be becoming more disabled, but should be improving with

more rehabilitation efforts. Staff has been unable to explain that continued therapies have been deemed unlikely to result in improvement by the treating physiatrist. Although restorative (maintenance) therapy may help slow the effects of her brain injury, e.g., by working on maintaining range of motion to slow spastic contractures, symptom progression is, unfortunately, an expected consequence of this injury.

The family feels the loss of Mrs. Doe’s presence acutely. Her daughter and husband describe how he wants to be able to spend their rest of their lives together in their family home, participating in all family activities. Before she was injured she was always there for them, caring for the grandchildren she loves, making holidays and other family occasions special.

Their earnest desire is for him to fulfill his duty as a husband by providing her the best quality of life possible at home, with appropriate care and other supports, so she can be present for and participate in her family’s life as much as possible. He strongly feels the responsibility as a husband to do this for her.

CURRENT STATUS

I visited the Care Center Rehabilitation Center on March 5, 2013. I reviewed their current records and spoke to staff about her condition and function. The therapist spoke with me at some length. She noted that Mrs. Doe has marked spasticity in all limbs, left, greater than right; this is managed with hand splints as previously noted. She is supposed to wear leg braces three hours per day while in bed. She has had occasional episodes of increased alertness, during which they have reinstituted therapies; however, she does not meet even modest goals and is discharged from therapies within a few weeks.

Mrs. Doe does feed herself part of her meals with a built-up spoon and adapted bowl. However, she soon tires or forgets (as per Dr. Washington’s opinion on abulia) and staff feeds her the rest of her meal as possible. Her weight has remained fairly stable.

The tilt-in-space wheelchair, on loan from the facility, remains in use for positioning and safety.

Mrs. Doe is incontinent. Although normally a goal would be to institute a program of intermittent toileting for bladder training, her increasingly severe spasticity when she is moved requires a tilt-in-space commode and a specialized lift system to protect staff from injury, which the facility

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12 Jane Doe Date

does not have and Medicaid will not cover for institutional use. Therefore for her own safety and that of the staff, her bowel and bladder are managed with diapers.

By previous arrangement, Dr. Wilson, a neuropsychologist saw Mrs. Doe that day for an evalua-

tion using a medical interpreter. I had previously provided him with medical records from Medical Center, ABC, and Mercy General Hospital per his request for review. He emphasized that this was a preliminary report, as she had tired within an hour. He shared his findings with Ms. Lincoln and me immediately afterwards.

He explained that she retained some old information, but had lost a number of old information and capabilities, such as names of many objects. Her reasoning and problem-solving were very severely affected. For example, she could repeat a string of three digits but could not repeat them backwards; she could not say how two objects were similar, e.g, same color, same shape, or used for a similar purpose. Her memory and attention span decreased very rapidly as they spoke. She should be considered completely unable to make any kinds of decisions or consider safety.

He felt that given the severity of her brain injury and the length of time since injury he would not expect her to make any improvement over time. He felt that she will need 24-hour care for the remainder of her life. He felt that it would be appropriate to use the memories she has, with pictures, visits, and so forth, and that some old memories might return, but not to expect any new learning due to the extent of brain damage. Mrs. Lincoln became very emotional after this assessment, saying she had suspected as much but had hoped that there would be some possibility of improvement. Mrs. Doe sat next to us in her chair and gave no indication that she understood or recognized her daughter’s tears and distress.

He returned to the facility a week later, with the interpreter, to complete his evaluation. His final report dated April 2, 2013 indicated that she was unable to perform a full battery of tests due to her physical and cognitive limitations. He found she had very significant impairments as a result of significant residual frontal lobe and temporal lobe dysfunction, including: • • • • • •

visual-spatial perception independent of corrective lenses encoding information into memory initiating actions (a safety hazard) inhibiting actions (a safety hazard) expressing needs (e.g., pain, discomfort, skin condition, medication side effects) functional abilities for activity of daily living (self care)

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13 Jane Doe Date

Dr. Wilson noted that her function is limited not only by her cognitive ability but also by her

physical impairments. He felt that some improvement in her abilities to perform activities of daily living might be possible if her physical impairments improve, but that this would actually result in an increased risk to her safety due to the ongoing cognitive impairments, which are not anticipated to improve. He notes that although medications can contribute to cognitive and physical symptoms, given the physical damage she suffered to her brain and the extent of her current deficits that medication is not likely to be a significant factor in her present disability.

He notes also that her memory of anything at the time of the accident is unlikely to be reliable and that people with missing memories are apt to confabulate (fill in with imagined or wishedfor memories), so that without independent corroboration she is not credible for actions requiring memory. As an example, I was present when she was asked where she was going at the time of her accident. She answered, “To the store.” When asked, “Which store?” her answer was, “JC Penney,” but there is no JC Penney store anywhere near there.

Dr. Wilson summarized that the time is likely past for significant cognitive and functional recovery after this injury, and that Mrs. Doe will need constant supervision, assistance, and skilled nursing care for the remainder of her life. This is congruent with Rancho Los Amigos Scale IIIIV. (See Appendix 1 for complete scale) I spoke with Nurse Kennedy, nurse practitioner in Dr. Johnson’s practice, about Mrs. Doe’s current condition and treatment plan. She felt that Mrs. Doe was stable. Although Care Center considers Dr. Johnson her attending primary care, with Nurse Kennedy, the family identifies Dr. Washington as her doctor. I spoke with Dr. Washington about Mrs. Doe’s current condition and anticipated treatment plan. He noted that she seems somewhat more alert and less tremulous on carbidopa/levodopa (Sinemet). He administered botulinum toxin (Botox) by injection to treat spasticity in her left leg on March 21; results are not clear yet as effects can take up to two weeks to appear and he had not reassessed her at the time of our phone call. He feels that she is medically stable. The current plan is to continue restorative therapy and current medications. If oral intake of fluids can be increased, the PEG tube may be removed.

HEALTH CARE PROVIDERS

The health care providers involved in Mrs. Doe’s care according to available medical records are outlined below.

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Health Care Providers from Records - * indicates current providers Provider

Address

Contact

14 Jane Doe Date

Specialty

Medical Center Thomas Jefferson MD, neurosurgery

Hospital

Mercy General Hospital

Hospital

ABC Rehabilitation Hospital

Acute rehabilitation

Major Rehab Dr. Paul Jackson

Subacute rehabilitation

Legacy Hall East

Skilled nursing

*Care Center Rehab and Nursing Joshua Johnson MD, geriatrics Meg Kennedy NP

Skilled nursing

*Barry Washington MD MPH

Physiatry

CURRENT MEDICAL ISSUES •

Parkinsonism

•

Spasticity, contractures, paralysis

•

Incontinence

•

Severe cognitive disability

•

Edentulous (no teeth)

CURRENT MEDICATIONS Except as noted, all are given per PEG tube •

Amlodipine (Norvasc, calcium channel blocker, blood pressure) 25 mg, daily

•

Atenolol (beta blocker, blood pressure) 12.5 mg (bedtime), daily; 25 mg daily, morning

•

Azelastine spray to nares (nasal allergies) 137 mcg/0.137 ml, twice daily

•

Baclofen (spasticity)15 mg, three times daily

•

Captopril (ACE inhibitor, blood pressure) 25 mg, three times daily

•

Carbidopa/levodopa (Sinemet, parkinsonism) 75 mg/300 mg, daily

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•

Escitalopram (Lexapro, depression) 10 mg, daily

•

Ferrex (iron supplement) 150 mg, daily

•

Levothyroxine (thyroid replacement) 137 mcg, daily

•

Multivitamin (dietary supplement) 1, daily

•

Simvastatin (Zocor, cholesterol) 20 mg, daily

•

Acetaminophen (Tylenol, pain or fever) 1300 mg, every four hours as needed

•

Bisacodyl (Dulcolax, constipation) 10 mg suppository, daily as needed

•

Disposable enema (Fleet’s) daily if no results from suppository, as needed

•

Ipratropium-albuterol (Duoneb, wheezing or shortness of breath) nebulizer, four times daily as needed

•

Senna (constipation) 8.6 mg, daily as needed

CURRENT TREATMENT PLAN •

Restorative therapies to prevent further contractures and skin breakdown

•

Botulinum (Botox) for spasticity

•

Water flushes 200 cc every six hours

•

Pureed meats, nectar-thick liquids

VOCATIONAL Mrs. Doe was a high school graduate in her native Germany. Mrs. Lincoln says this education is at a higher level than high school in this country, perhaps equivalent to a year of college. She has not worked outside the home since coming to the US. Before her injury she enjoyed holidays and cooking for her family, caring for her granddaughters, shopping, visiting with friends, and watching German-language television.

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LIVING ARRANGEMENTS

I visited the family home at 123 Russell Street, City ST (right) on March 6, 2013. According to two online real estate information databases (Zillow, Trulia), 123 Russell St. was built in 1900, has 3 bedrooms, 1 bath, and has approximately 972 square feet of livable floor space. The lot size is about 1,945 square feet. Its estimated value is $93,887, and its assessed value 20xx was $100,500. Until her accident, Mrs. Doe lived here with her husband.

The front door is accessible via four steps which begin at the sidewalk edge. There are parking spaces on both sides of the house; however, only one parking spot, on the right as you face the house, belongs to the property.

There is no garage and no way to provide covered access to the home for bad weather. There is no space available to install a ramp or lift.

The house is very small. The width of interior doors ranges from 21” to 29”. The width of the downstairs passageway between the front door and the kitchen is 31” wide. There is approximately 2 feet of clearance between the front door and the stairs. The picture at left was taken standing on the front porch outside the front door; the front door grazes the carpeting on the first step of the stairs when opened.

The stairs are very steep and narrow, about 32” wide.

They terminate in a right angle at a narrow upstairs hallway of approximately 31” wide. The space is too small to accommodate a stair lift at either the bottom or the top of the stairs. According to the Easter Seals Summary on Home Accessibility (Appendix 1) for wheelchairs, doorways should be at least 32” clear width, and hallways at least 42”, with 48-60” preferable for safe transport and turnaround.

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Downstairs is the living room/dining room, and kitchen, and the house’s only bathroom. The bathroom is off the dining area. Its 22” door is visible in the far right corner of the living room/dining room next to the only window (above right).

The bathroom (right) is approximately 40” inches wide and contains a toilet, small standard vanity, and standard shower stall about 26” square with a 5” lip. The window is visible behind the shower and above the bulkhead (below right). The size of the free floor space is approximately 2’2” x 4’ (the floor tiles are 12” square, for scale).

There is no way to expand the size of the bathroom inside the house; outside the bathroom area is the bulkhead access to the cellar. The house appears to sit very close to the lot line, so it would not be possible to expand in that direction. The Easter Seals Summary notes that a wheelchair-accessible bathroom should have a 32” doorway and at least a 5’ x 5’ clear floor space to accommodate a normal wheelchair turning radius, have a roll-under vanity top, a roll-in shower, and a raised or wall-mounted toilet.

The kitchen is about 9’ wide. There are three doors, one to the cellar (22”), one to the dining room area (21”) and bathroom, and one to the back deck (31”)

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(visible in picture, bottom of previous page). The deck is approximately 16’ x 12’ and was built

by Mr. Doe’s son-in-law. There are several stairs from the deck to the ground level. The lot has no place to site a ramp for entrance or safe second exit.

There are three rooms upstairs, each with a 28” door. One room, in the front of the house, is very large, extending the width of the house, approximately 12’ x18’ (door and hallway visible in picture at right). It is heated with one steam radiator and has two windows, visible at the front of the house.

The other two rooms in the back of the house (left) are each approximately 9’ x 10’. One, above the kitchen, has a small steam radiator for heat. The other, above the dining room and bathroom (vent stack visible in corner behind bed), has no heat.

Each has one window over-looking the back of the lot. There is no bathroom upstairs. There is no means of emergency egress except the front stairs, and, as noted, the hall is too narrow for a wheelchair.

There is no air conditioning in the house. According to published annual weather statistics from NOAA, average daytime temperatures in City range from 3485 degrees F, and nighttime temperatures from 18-63 degrees F. 3 I observed no smoke detectors in the house. Please refer to the Easter Seals Summary attached to compare these features to the standards for a wheelchair-accessible home.

Mrs. Doe is completely dependent for all activities of daily living. Access and facilities would need to be

3

http://http://www.weather.com/weather/wxclimatology/monthly/graph/01089 retrieved March 29, 2013

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safe for Mrs. Doe and at least one caregiver plus adaptive equipment, lifting equipment, ramps, and the like. In my opinion, this house is not modifiable to meet accessibility or safety needs.

Therefore to meet the family’s wish to have her at home with them, alternative housing will be needed, either constructed or modified to meet standards for safety and access. Provisions for this are included in the tables.

CURRENT FUNDING AND INCOME

According to Mr. Doe, interpreted by his daughter, Mrs. Doe’s care is mostly funded by Medicaid now that her private health insurance is exhausted. He is disabled after a back injury and works 12 hours per week in a modified job. Mrs. Lincoln and her husband pay approximately $125/month for her to have internet access for German-language television, personal services (podiatry, haircutting, etc.), dental care, laundry, and miscellaneous expenses that are not covered by Medicaid.

LIFE EXPECTANCY

Normal life expectancy for a 60-year-old non-Hispanic white female is 24.5 more years. 4 However, Mrs. Doe’s life expectancy can be considered to be less due to her traumatic brain injury and residual disability. According to Shavelle et al. and Ratcliffe et al., the life expectancy for a woman with traumatic brain injury at age 50 who is unable to walk as the result of her brain injury is 11 years post injury. 5,6 Though statistics for a woman aged over sixty are not given, experience suggests that this number would be lower. Dr. Washington, treating physiatrist, agreed with this and estimates a life expectancy of about ten years, barring unforeseeable circumstances. Lifetime costs are therefore projected for ten years post injury (20xx), another 8.5 years from the date of this plan.

SUMMARY

Future Routine Medical Care The following can be anticipated: •

4 4

Neurologist and neurosurgeon: Monitor status, condition, drug levels, ventriculoperitoneal shunt; head CT scan every three to five years would be beneficial to follow progressive brain atrophy, potential complications such as hydrocephalus, or other structural changes

National Vital Statistics Reports, Vol. 61, No. 6, October 10, 2012, Table 6, p. 27

Shavelle RM, Strauss DJ, Day SM, Ojdana KA (2007). Life Expectancy. In: ND Zasler, DI Katz & RD Zafonte (Eds.), Brain Injury Medicine: Principles and Practice. New York: Demos Medical Publishing.

6 Ratcliff G, Colantonio A, Escobar M, Chase S, and Vernich L. Long-term survival following traumatic brain injury. Disability and Rehabilitation, 2005, Vol. 27, No. 6 , Pages 305-314

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•

• • •

Physiatrist: Therapy plan, evaluate spasticity for repeat botulinum and/or implanted baclofen pump, pump refills (if needed), monitor orthopedic condition, could assume role of primary care physician for routine medical care Primary care: routine physical examinations, laboratory studies; immunizations, annual: Pneumovax, influenza (Physiatry can assume primary care role) Podiatrist: care of ingrown nails (a common complication) Nurse case management: care coordination, interspecialty communication, patient/family teaching and support

Future Medical Care, Surgical Intervention, or Aggressive Treatment As noted above, repeated botulinum and/or an intrathecal baclofen pump for spasticity relief to allow better positioning may be indicated at some time in the future. Surgical release of contractures may be needed at some time in the future.

Projected Evaluations Mrs. Doe is presently using a loaner wheelchair at Care Center. Before discharge home she will need to have a wheelchair evaluation for seating and mobility by a professional (not a vendor) for her own tilt-in-space chair and tilt-in-space commode/shower chair. This would be advisable even if she remains in a facility.

Projected Therapeutic Modalities Repeat botulinum therapy may be indicated for continuing spasticity management. The possibility of using an implantable baclofen intrathecal pump may be considered in the future if botulinum decreases in effectiveness, produces unwelcome side effects and spasticity management is still needed. Costs for this are included in the plan with the understanding that actual use will depend on future evaluations by physiatry and neurosurgery.

Wheelchair Needs/Mobility/Maintenance

Her treating team anticipates that Mrs. Doe will

continue to need a manual tilt-in-space wheelchair with a Roho cushion to reduce risk of pressure ulcer. Though it is unlikely that Mrs. Doe’s weight will change substantially, the fit and seating surface should be reevaluated annually to account for changes in positioning needs caused by increasing or decreasing contractures or weight change.

Wheelchair Accessories Wheels will likely need to be replaced every 2 years. A specialty wheelchair cushion lasts approximately one year when used daily. Arm rests, leg rests, head rest, foot plates, and belts will need replacement every 2-3 years. The chair will require repairs every 1-2 years and replacement every 5-7 years. 7 7

PMSI, 2009. All equipment replacement schedules assume manufacturer’s recommended maintenance schedule has been used

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Orthotics/Prosthetics Arm splints and leg brace will need replacement every one to two years, and more often if her contractures worsen. A second set should be provided to allow for cleaning.

Medical Equipment A rolling shower stretcher or tilt-in-space shower chair should used daily for showering. The accessible shower should have a hand-held shower head with integral turnoff for safety. A tilt-in-space commode will allow her to be less dependent on diapers. She will

need a lift system for bed-chair-commode-shower stretcher mobility for her safety and that of her caregivers; this will improve her hygiene and quality of life.

Mrs. Doe will need a hospital bed with a non-shear, pressure relieving mattress overlay or specialty mattress for moisture management and to decrease risk of pressure ulcer. Most specialty beds will accept lightweight jersey sheets available at consumer stores, so special linens are not needed.

As she ages it would be prudent to plan for decreased swallow ability, and provide for PEG tube replacement and a feeding tube pump, and related supplies for nutrition and hydration.

Drug/Supply Needs

It seems likely that Mrs. Doe will continue to need disposable adult

diapers, wipes, gloves, and bed pads to manage incontinence even if mobility aids make commode and shower use more feasible. Special cleaning solutions or laundry facilities are not necessary for home care. Refer to the list previously in the report and to the list in the tables for complete medications and related supplies. Medication and supply costs are based on the supplier in current use. Generics are being used where available. Note that Care Center does not include medications in the daily room rate.

Home Care/Facility Care Mrs. Doe will need 24-hour care at home from home health aides with bimonthly supervision from a registered nurse. As this will include awake care at night, no additional sleeping facilities will be required. Follow up by a registered physical therapist to reinforce home exercise routines by the aides and family should be provided every six months or more often as prescribed by the treating physiatrist depending on periodic reevaluations.

Transportation The safest way to transport Mrs. Doe would be by a commercial lift-equipped van; this would relieve Mr. Doe of the physical burden of managing her and driving an unwieldy vehicle.

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Other Services

The cost of future medical care and anticipated complications could be

22 Jane Doe Date

decreased through expert coordination of medical care by a certified registered nurse case manager (CCM and/or RN-BC) with expertise in brain injury, very strongly recommended.

Services of a registered dietician with expertise in brain injury, tube feedings (if necessary in the future), and caloric expenditures of spasticity would be helpful to maintain positive protein balance for tissue repair and optimal immune function. Guardianship and financial management would be advisable to manage any financial resources should her family members become unable or unwilling to serve in this capacity.

Architectural Renovations As noted, the Doe family home is not suitable for remodeling. An alternative should be sought. According to several real estate agents in the City area, a representative sample within several miles of the present home includes 3-4 bedroom accessible housing in the range of $114,900 - $300,000.

An alternative to an already-accessible home would be buying a home and remodeling it for safety and accessibility. According to several NARI-certified builders, ramps, lifts, and bathroom modifications for an average house would cost in the $40,000-$70,000 range. As Mrs. Doe will not be using the kitchen, no kitchen modifications will be necessary. A CAPS (certified aging in place specialist) and NARI (National Association of the Remodeling Industry)-certified provider in western State will evaluate whatever housing is found for the Does for specific recommendations (see table for contact information).

An installed lift system, e.g., SureHands or Helping Hands, will facilitate safe lifting, transfers, and bathroom use. This can be installed in the home or be free-standing to avoid structural members. Some representative installations are demonstrated at http://www.youtube.com/watch?v=3RaJUceRwIE and http://www.youtube.com/watch?v=rqFYvVrBVBw Potential Complications Skin: • Decreased mobility, decreased sensation or awareness, increased moisture, spasticity, and changes in the fit and usage of equipment can lead to pressure ulcers, formerly called decubitus ulcers, and prevent healing once they develop. These develop close to the bone, so by the time a break in the skin is visible, damage can be severe. At present Mrs. Doe’s

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risk factors for pressure ulcers include immobility, braces and splints, incontinence, and cognitive impairment. A low-air-loss, non-shear mattress or overlay and similar wheelchair cushion will be helpful to protect her skin.

•

Medical care should be sought quickly for small skin lesions, especially in pressure areas.

Care of a pressure ulcer should be provided by a specialist team in wound care and healing (plastic surgery).

•

A podiatry consult should continue twice annually to check for pressure areas on the feet and for prevention and care of ingrown nails.

•

Daily skin checks throughout the body should be performed to detect potential areas of breakdown, since Mrs. Doe will likely not be aware of them if they occur.

Infection: • As noted, breaks in the skin are risks for systemic infection.

•

Urinary tract infections are a common cause of morbidity and mortality in disabled persons.

•

Mrs. Doe is at high risk for pneumonia from aspiration, as a complication of influenza, or pulmonary secretions pooling as a result of prolonged immobility.

Fractures: • Mrs. Doe is postmenopausal and immobile. Both are factors that increase risk of fracture.

Note on Projected Costs

When exact costs are not available and a range given, the number used in the total is the average within the range. Costs noted are 90% of UCR 8; contracted rates or actual billed amounts may vary by payor.

8 Medical Fees in the United States 2013, PMIC, Los Angeles CA. Copyright 2013, American Medical Association. ISBN: 978-1936977-38-3

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Life Care Plan Table of Contents

Appendix 1, Function of the Brain by Lobe Appendix 2, Rancho Los Amigos scale

…

…

25

27

Appendix 3, Easter Seals summary on home accessibility Tables

…

Page

Future Routine Medical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i

Projected Evaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i - ii

Wheelchair Needs/Mobility/Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ii - iii

Orthotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iv

Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iv - v

Drug/Supply Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

vi - vii

Home Care/Facility Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

viii

Future Medical Care, Surgical Intervention, or Aggressive Treatment . . . . . viii - ix Potential Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ix - x

Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

x

Other Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xi

Architectural Renovations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xi - xii

Lifetime Cost Projection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xiii

31

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Appendix 1 Parietal Lobe Functions • Sense of touch • Spatial perception • Differentiation (identification) of size, shapes, and colors • Visual perception Occipital Lobe Functions • Vision Cerebellum Lobe Functions • Balance • Skilled motor activity • Coordination • Visual perception Brain Stem Functions

• • • • •

Breathing Arousal and consciousness Attention and concentration Heart rate Sleep and wake cycles

Frontal Lobe Functions • Attention and concentration • Self-monitoring • Organization • Speaking (expressive language) • Motor planning and initiation • Awareness of abili-

• • • • • • •

ties and limitations Personality Mental flexibility Inhibition of behavior Emotions Problem solving Planning and anticipation Judgment

Temporal Lobe Functions • Memory • Understanding language (receptive language) • Sequencing • Hearing • Organization

Functions of Brain by Lobe

continued next page

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Injuries of the left side of the brain can cause: • Difficulties in understanding language (receptive language) • Difficulties in speaking or verbal output (expressive language) • Catastrophic reactions (depression, anxiety) • Verbal memory deficits • Impaired logic • Sequencing difficulties • Decreased control over right-sided body movements Injuries of the right side of the brain can cause: • Visual-spatial impairment • Visual memory deficits • Left neglect (inattention to the left side of the body) • Decreased awareness of deficits • Altered creativity and music perception • Loss of “the big picture” type of thinking • Decreased control over left-sided body movements Diffuse Brain Injury (The injuries are scattered throughout both sides of the brain) can cause: • Reduced thinking speed • Confusion • Reduced attention and concentration • Fatigue • Impaired cognitive (thinking) skills in all areas

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Appendix 2

Rancho Los Amigos Cognitive Scale, Revised Levels of Cognitive Functioning

Los Amigos Research and Educational Institute, 1990

Level I - No Response: Total Assistance

Complete absence of observable change in behavior when presented visual, auditory, tactile, proprioceptive, vestibular or painful stimuli.

Level II - Generalized Response: Total Assistance • Demonstrates generalized reflex response to painful stimuli.

• Responds to repeated auditory stimuli with increased or decreased activity.

• Responds to external stimuli with physiological changes generalized, gross body • •

movement and/or not purposeful vocalization.

Responses noted above may be same regardless of type and location of stimulation.

Responses may be significantly delayed.

* Level III - Localized Response: Total Assistance • Demonstrates withdrawal or vocalization to painful stimuli.

• Turns toward or away from auditory stimuli.

• Blinks when strong light crosses visual field.

• Follows moving object passed within visual field.

• Responds to discomfort by pulling tubes or restraints.

• Responds inconsistently to simple commands.

• Responses directly related to type of stimulus.

• May respond to some persons (especially family and friends) but not to others. * Level IV - Confused/Agitated: Maximal Assistance • Alert and in heightened state of activity.

• Purposeful attempts to remove restraints or tubes or crawl out of bed.

• May perform motor activities such as sitting, reaching and walking but without any • • • • • • •

apparent purpose or upon another's request.

Very brief and usually non-purposeful moments of sustained alternatives and divided attention.

Absent short-term memory.

May cry out or scream out of proportion to stimulus even after its removal.

May exhibit aggressive or flight behavior.

Mood may swing from euphoric to hostile with no apparent relationship to environmental events.

Unable to cooperate with treatment efforts.

Verbalizations are frequently incoherent and/or inappropriate to activity or environment.

Level V - Confused, Inappropriate Non-Agitated: Maximal Assistance • Alert, not agitated but may wander randomly or with a vague intention of going

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• • • • • • • • • • • •

home.

May become agitated in response to external stimulation, and/or lack of environmental structure.

Not oriented to person, place or time.

Frequent brief periods, non-purposeful sustained attention.

Severely impaired recent memory, with confusion of past and present in reaction to ongoing activity.

Absent goal directed problem solving, self-monitoring behavior.

Often demonstrates inappropriate use of objects without external direction.

May be able to perform previously learned tasks when structured and cues provided.

Unable to learn new information.

Able to respond appropriately to simple commands fairly consistently with external structures and cues.

Responses to simple commands without external structure are random and nonpurposeful in relation to command.

Able to converse on a social, automatic level for brief periods of time when provided external structure and cues.

Verbalizations about present events become inappropriate and confabulatory when external structure and cues are not provided.

Level VI - Confused, Appropriate: Moderate Assistance • Inconsistently oriented to person, time and place.

• Able to attend to highly familiar tasks in non-distracting environment for 30 minutes • • • • • • • • • • •

with moderate redirection.

Remote memory has more depth and detail than recent memory.

Vague recognition of some staff.

Able to use assistive memory aide with maximum assistance.

Emerging awareness of appropriate response to self, family and basic needs.

Moderate assist to problem solve barriers to task completion.

Supervised for old learning (e.g. self care).

Shows carry over for relearned familiar tasks (e.g. self care).

Maximum assistance for new learning with little or nor carry over.

Unaware of impairments, disabilities and safety risks.

Consistently follows simple directions.

Verbal expressions are appropriate in highly familiar and structured situations.

Level VII - Automatic, Appropriate: Minimal Assistance for Daily Living Skills • Consistently oriented to person and place, within highly familiar environments. Mod• • • • •

erate assistance for orientation to time.

Able to attend to highly familiar tasks in a non-distraction environment for at least 30 minutes with minimal assist to complete tasks.

Minimal supervision for new learning.

Demonstrates carry over of new learning.

Initiates and carries out steps to complete familiar personal and household routine but has shallow recall of what he/she has been doing.

Able to monitor accuracy and completeness of each step in routine personal and household ADLs and modify plan with minimal assistance.

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• • • • • • • •

Superficial awareness of his/her condition but unaware of specific impairments and disabilities and the limits they place on his/her ability to safely, accurately and completely carry out his/her household, community, work and leisure ADLs. Minimal supervision for safety in routine home and community activities.

Unrealistic planning for the future.

Unable to think about consequences of a decision or action.

Overestimates abilities.

Unaware of others' needs and feelings.

Oppositional/uncooperative.

Unable to recognize inappropriate social interaction behavior.

Level VIII - Purposeful, Appropriate: Stand-By Assistance • Consistently oriented to person, place and time.

• Independently attends to and completes familiar tasks for 1 hour in distracting envi• • • • • • • • • • • • • • •

ronments.

Able to recall and integrate past and recent events.

Uses assistive memory devices to recall daily schedule, "to do" lists and record critical information for later use with stand-by assistance.

Initiates and carries out steps to complete familiar personal, household, community, work and leisure routines with stand-by assistance and can modify the plan when needed with minimal assistance.

Requires no assistance once new tasks/activities are learned.

Aware of and acknowledges impairments and disabilities when they interfere with task completion but requires stand-by assistance to take appropriate corrective action.

Thinks about consequences of a decision or action with minimal assistance.

Overestimates or underestimates abilities.

Acknowledges others' needs and feelings and responds appropriately with minimal assistance.

Depressed.

Irritable.

Low frustration tolerance/easily angered.

Argumentative.

Self-centered.

Uncharacteristically dependent/independent.

Able to recognize and acknowledge inappropriate social interaction behavior while it is occurring and takes corrective action with minimal assistance.

Level IX - Purposeful, Appropriate: Stand-By Assistance on Request • Independently shifts back and forth between tasks and completes them accurately for • • •

at least two consecutive hours.

Uses assistive memory devices to recall daily schedule, "to do" lists and record critical information for later use with assistance when requested.

Initiates and carries out steps to complete familiar personal, household, work and leisure tasks independently and unfamiliar personal, household, work and leisure tasks with assistance when requested.

Aware of and acknowledges impairments and disabilities when they interfere with task completion and takes appropriate corrective action but requires stand-by assist

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• • • • • • •

to anticipate a problem before it occurs and take action to avoid it.

Able to think about consequences of decisions or actions with assistance when requested.

Accurately estimates abilities but requires stand-by assistance to adjust to task demands.

Acknowledges others' needs and feelings and responds appropriately with stand-by assistance.

Depression may continue.

May be easily irritable.

May have low frustration tolerance.

Able to self monitor appropriateness of social interaction with stand-by assistance.

Level X - Purposeful, Appropriate: Modified Independent • Able to handle multiple tasks simultaneously in all environments but may require pe• • • • • • • • •

riodic breaks.

Able to independently procure, create and maintain own assistive memory devices.

Independently initiates and carries out steps to complete familiar and unfamiliar personal, household, community, work and leisure tasks but may require more than usual amount of time and/or compensatory strategies to complete them.

Anticipates impact of impairments and disabilities on ability to complete daily living tasks and takes action to avoid problems before they occur but may require more than usual amount of time and/or compensatory strategies.

Able to independently think about consequences of decisions or actions but may require more than usual amount of time and/or compensatory strategies to select the appropriate decision or action.

Accurately estimates abilities and independently adjusts to task demands.

Able to recognize the needs and feelings of others and automatically respond in appropriate manner.

Periodic periods of depression may occur.

Irritability and low frustration tolerance when sick, fatigued and/or under emotional stress.

Social interaction behavior is consistently appropriate.

Original Rancho Los Amigos Cognitive Scale co-authored by Chris Hagen, Ph.D., Danese Malkmus, M.A., Patricia Durham, M.A., Rancho Los Amigos Hospital, 1972.

Revised 11/15/74 by Danese Malkmus, M.A., and Kathryn Stenderup, O.T.R.

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Appendix 3

Easter Seals Summary on Home Accessibility Home Adaptability Checklist A home may be considered adaptable if it has all or most of the following key structural features that allow reasonable entry and circulation without extensive modification: * Located on a relatively flat or level site with paved walkways from parking (covered is preferred) and sidewalk areas to level entry * A ground-level entrance or a one or two step entrance clear of any major obstructions, i.e. trees, building corners, etc., that would accept a ramp with a slope no greater than 1" height per 12" in length * No steps or abrupt level changes on main floor * Wider-than-standard doorways (32" or more clear width); 1/2" high maximum thresholds * Wide hallways at least 42"; preferably 48"- 60" * At least one large bathroom with a 32" clear door opening and clear 5'x5' floor space * A kitchen large enough for easy wheelchair mobility (U or L shaped or open plan preferred) Accessibility Checklist When you preview a house for accessibility, specifically wheelchair, note each item that is presently available. Individual access needs vary greatly. Wheelchairs are used for different reasons and come in many different sizes, so while one person using a wheelchair may be able to get through a 32 inch doorway, another may need 36 inches. Where a range of measurement is indicated on the accessibility checklist, note the exact width or height in the space provided.

The list will provide the user with a measure of existing accessibility features.

Certainly all of these features are not necessary or even desirable, to meet the needs of an individual with a disability. This checklist is intended to generate enough information about any given home to let people interested in accessibility features know if it warrants consideration. At the end of the checklist, you will find some general adaptation tips and resources. * One-story building * Multilevel house with main level accessible

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32 Jane Doe Date

- entrance - bathroom - bedroom * Level entry way or ramp with entry level landing for easy door opening * Wide doorways (32" 36" clear width) * Wide hallways (42" - 60") * Low-pile carpeting with thin padding * Chair-height (48" 54") doorbell/mailbox * Chair-height electrical controls/outlets (excluding the kitchen, generally controls are 6" lower and outlets are 6" higher than standard) * Chair-height push-button telephones/jacks * Accessible, easily operated window controls, i.e., slide to side, can be opened with one hand or less than eight pounds of pressure, located 24"-28" from floor * Direct outside emergency exit from bedroom * Audio and visual smoke detectors * Large windows, overhead lighting or several electrical outlets in each room.

(Lighting is a big consideration for persons with low vision.) *(Note: Chair-height is defined as how far a person using a wheelchair can reach.

Using a front approach, chair-height for a person using a wheelchair is approximately 48 inches. Using a parallel approach, chair-height is about 54 inches.) * Front control-operated range * Countertop range * Lowered wall oven (30"- 42") * Side by side, frost-free, dispenser-type refrigerator * Varying countertop and cabinet heights * Counters with pullout cutting boards * Front control-operated, built-in dishwasher * Front loading washer/dryer * Outswing doors * Nonslip floors * Grab bars * Reinforced walls (i.e., 3/4" plywood backing throughout) for installation of grab bars * 5' square clear area (required for most wheelchair users to make a 360 degree turn). Since many wheelchair users can function in smaller areas, measure exact clear floor space if less than 5' * Chair-height racks/shelves/cabinets

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33 Jane Doe Date

* Lever hand faucets * Lowered or tilted mirror * Roll-under vanity top * Hinged, fold-down seat in shower * Roll-in shower with no curb * Handheld or adjustable shower head * Bathtub with nonskid strips or surface * Toilet seat 17"- 19" from floor; or wall mounted toilet * Telephone outlet * Open floor plan * Built-in cabinets have 6" baseboard recess * Built-in wall bed * Direct access to accessible bathroom * Reinforced ceiling (to accommodate pulleys for lifting mechanisms) * Sliding doors or bi-folding doors * Adjustable shelves and hanging rods * Shallow shelves no more than 18" deep Garage * Attached * Oversized * High ceiling (9'6" needed to accommodate a raised-top van) * Automatic door opener * On or near public transportation * Conveniently located to shopping area

Chapter 10: Creating Professional Curriculum Vitae | 1165

Chapter

10 Creating Professional Curriculum Vitae An expert witness provides opinion testimony based upon his or her specialized knowledge, experience, or training. The courts define the parameters of expert testimony and outline admissibility standards, such as Frye or Daubert.

The expert must show specialized knowledge and ability beyond that of the layperson usually through a curriculum vitae.

Curriculum vitae is Latin, loosely translated as “the course of one’s life (Merriam-Webster, 2014).” It’s an account of the career and qualifications that prepare the writer for a position, here, as an expert witness.

There is no right way to write a CV. However there are things that can make it easier to read and to appear more professional.  Keep your CV up to date  Make it well-organized and logical  Avoid using a variety of styles and fonts within the document

 Sections commonly used, in various order: Education Honors and awards Professional experience/employment Publications and presentations Relevant extracurricular and volunteer experiences Certifications and licensure Professional affiliations, activities, and research Unlike a resume, the CV can be as long as it needs to be.

In an effort to get to know our contributors, evaluate their expertise, consult on a plan, or for hiring purposes, the curriculum vitae for each contributor is included herein. Planners are encouraged to analyze these CVs to see what layout/formats are most appealing and seek to incorporate some of these patterns or arrangements for personal use.

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Victoria Powell, RN, CCM, LNCC, CNCLP, CLCP, MSCC, CEASII, CBIS 1201 Military Road, Ste. 2, Box #214, Benton, Arkansas 72015 501-778-3378 or Victoria@VP-Medical.com

Licensure/Certification RN licensure (1994) #R049631 Legal Nurse Consultant Certified (2006) #57921 Certified Case Manager (2004 & 2008) #00071936 Certified Nurse Life Care Planner (2007) #3120741R Certified Life Care Planner (2007) #1141 Medicare Set-Aside Consultant Certified (2007) #0522 Certified Ergonomic Assessment Specialist (2004) Certified Ergonomic Assessment Specialist Level II (2006) Certified Brain Injury Specialist (2014) #13822

Professional Experience Registered Nurse: Graduated with honors. Began practice at the bedside in a Med-Surg unit. Trained as charge nurse for the unit. Experience in a long-term, ventilator dependent, step-down unit. Nurse Manager for neurodiagnostic center and trained in electrodiagnostic studies. Office manager for large multispecialty orthopedic group. Neuromuscular sales representative with proven sales record. Was designated the nurse trainer in association with a national medical case management firm. Currently practicing community care nursing to include medical and catastrophic case management as well as Life Care Planning, Medicare Set Aside allocations, ergonomic assessments, community health education, and Legal Nurse Consulting.

Certified Medical Case Manager: Case manager since 2002; certified since 2004. Duties include coordinating resources and creating flexible, cost effective options for catastrophically or chronically ill or injured individuals on a case by case basis to facilitate quality, individualized treatment goals.

Facilitate communication and coordination among all members of the health care team to minimize fragmentation of the health care delivery system. Provide liaison services for the individual and the providers, as well as the community. Encourage appropriate use of medical facilities and services, improve quality of care, independent function, and maintain cost effectiveness. Experienced in workers compensation case management, catastrophic case management, as well as private care management.

Legal Nurse Consultant Certified: Began practicing in this role in 2002; certified since 2007. Utilize current nursing skills, knowledge, education and expertise to screen cases for merit or perform comprehensive review of medical records, research Standards of Care, locate expert witnesses, create demonstrative evidence for the courtroom and present written and oral opinions on nursing and medical aspects of cases. Completed Core Curriculum for Legal Nurse Consulting sanctioned by the American Association of Legal Nurse Consultants (AALNC) and received specialty certification recognized by the American Nurses Credentialing Center (formerly ABNS) in 2007. Experienced with both plaintiff and defense work in medical malpractice, personal injury, toxic tort, family law, and workers compensation cases.

Certified Nurse Life Care Planner: Develop lifelong care plans, utilizing nursing diagnoses and the nursing process, for those with catastrophic injury or illness. The plans help to outline medical and nonmedical needs and the costs associated with care which is often documented in medical malpractice and personal injury cases as well as many workers compensation cases. The plan not only outlines costs used in determination of damages, but it also acts as a plan of care and budget tool for the injured party over

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their lifetime. Utilizing an abbreviated form of the plan, I provide medical cost projections for claims when requested; often used when setting insurance reserves or preparing for mediation. The plans have been used to assist trust companies in structuring settlement funds to best serve the trustee’s longterm needs. Certification received in 2007 from Nurse Life Care Planner Cert Board. Also received certification from the International Commission on Health Care Certification (ICHCC) as a Certified Life Care Planner in 2009.

Certified Medicare Set-Aside Consultant: Certification requires knowledge in the complex area of Medicare Set Aside allocations as it relates primarily to protecting Medicare’s interest in accordance with Section 111 of the Medicare as Secondary Payer Act. Requires knowledge of Medicare guidelines, coding, cost analysis, and research. Services provided for both workers compensation and liability cases.

Obtained certification from the International Commission on Health Care Certification in 2007.

Certified Ergonomic Assessment Specialist: OSHA-compliant ergonomics analysis for industrial & office jobs. Completed an additional advanced level certification for enhanced skills in ergonomics job assessment with use of evaluation tools, techniques for cost effective solutions, compiling client reports and developing proposals as well as the impact of ergonomics on the aging workforce. Obtained Level I certification in 2004 and Level II certification in 2006.

Certified Brain Injury Specialist: Nationally recognized certification demonstrating expertise in working in brain injury services obtained in 2014 by training and exam with continuing education requirements of 8 hours per year specifically within brain injury. This certification demonstrates that the holder is dedicated to providing improved quality of care for persons with brain injury.

Education x x x x x x x x x x x

University of Florida, Risk Management Course, 80 hours 2012-2013 University of Florida, Forensic Science for Nurses Course, 80 hours 2012-2013 Chamberlain College of Nursing, course work toward BSN Kelynco, Inc., Salt Lake City, UT, Nurse Life Care Planning certificate, 2007 Kelynco, Inc., Salt Lake City, UT, Medicare Set Aside certificate, 2007 LNI Institute, Tampa, FL, Advanced Legal Nurse Consulting certificate, 40 hrs., 2006 Back School of Atlanta, Atlanta, GA, Certification in Ergonomic Assessment, 2004 and Advanced certification in 2006 Baptist School of Nursing, Little Rock, AR, Nursing Diploma 1994 Henderson State University, Arkadelphia, AR, Nursing, Undergraduate Studies, 1991-1993 University of Arkansas at Little Rock, Little Rock, AR, Business Administration Undergraduate Studies, 1985-1986 Benton High School, Benton, AR, Graduate Diploma, 1985

2005–present VP Medical Consulting, LLC (Benton, AR) Consultant x Legal Nurse Consulting; plaintiff and defense work x Nurse Life Care Planning; plaintiff and defense x Worker’s Compensation Case Management-independent practice x Ergonomic Assessments for industrial and office positions

December 11, 2014

Employment History

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x x x x x x

Private Care Management Medicare Set-Aside Consultant In Home Fall Assessments Long Term Disability Assessments Community Health Education Bill Review consultant

2002–2005 GENEX Services, Inc. (Oklahoma City, OK) Medical Case Manager x Work related injuries x Catastrophic cases x Long Term Disability x Trainer for Arkansas staff case managers 2000–2002

RS Medical, Inc. (Vancouver, WA)

Sales Representative x x

Neuro-muscular stimulator sales Patient and physician education

2000-2000 St. Joseph’s Regional Health Center (Hot Springs, AR) Registered Nurse x Step-down unit for ventilator dependent patients x Long term illness unit

1995-1999 Arkansas Neurodiagnostic Ctr. (Little Rock, AR) Registered Nurse / Office Manager x Managed two physicians and 8 staff in three locations x Neurodiagnostic technician (EMG/NCVS) x Physician hospital rounds x Patient education x Research coordinator for pharmaceutical drug studies x Records and employee management x Accounts payable/receivable clerk x Area of focus-general neurology, movement disorders, neurodiagnostic testing, head injury, peripheral neuropathy

December 11, 2014

1999-2000 Arkansas Specialty Orthopedics (Little Rock, AR) Care Center Manager x Managed 8 physicians and 36 employees spread over 9 locations x Worked with case managers to obtain and coordinate patient care x Responsible for billing practices of the clinic, supervised certified coders and collectors x Participated in educational and community projects such as Arthritis Foundation Jingle Bell Run and Susan B. Komen Race for the Cure

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1992-1995 Saline Memorial Hospital (Benton, AR) Registered Nurse (1994-1995) x Med-Surg staff nurse x Primarily Cardiac and Respiratory patients x Unit Charge Nurse Patient Care Technician (1992-1994)

Special Interests x x x x x x

Life Care Planning Amputation Orthopedic and neurological injury Workers compensation Ergonomics Dental and Orthodontic Cases

Professional Affiliations

x x

x x x x x x x x x x x x

American Association of Nurse Life Care Planners (AANLCP) o Executive Board Member President Elect (2014-2015) President (2015-2016) Past President (2016-2017) o Board representative to the Nursing Organizations Alliance o Marketing liaison to AANLCP Executive Board (2013) o Journal committee member (2011-2014) o Editorial board member (2009-2011) o Conference committee member (2009-2011) o Marketing Committee Chairperson (2009-2011) Association of Rehab Nurses (ARN) National Nurses in Business Association (NNBA) o

NNBA Lifetime Hall of Fame Recipient in 2011-for contribution of the greatest value to the promotion, support and education of nurses in business; a tribute for the difference made in the lives of like-minded nurses and all humanity

American Association of Legal Nurse Consultants (AALNC) o Previously served as President of the Arkansas Chapter of AALNC Juris Educational Resource Knowledge for LNCs Case Management Society of America (CMSA) Active member of the Little Rock Chapter of CMSA North American Medicare Set Aside Professionals (NAMSAP) Academy of Legal Medicine (ACLM) Current member of Amputee Coalition of America (ACA) Current member of the American Amputee Foundation Past Member of Academy of Certified Case Managers (ACCM) Past member of American Association of Neuroscience Nurses (AANN) Past member of National Association of Physician Nurses (NAPN) Past member of the American Association of Electrodiagnostic Technicians (AAET)

December 11, 2014

x

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Professional Education for the past 12 months November 7, 2013 AANLCP Restart, Refresh, Refocus (7 hours) Philadelphia, PA

November 8-10, 2013 American Association of Nurse Life Care Planners Annual Conference (15.5 hours) Philadelphia, PA March 5-9, 2014 Leisure & Learn Workshop Ajijic, Jalisco, MX (30 hours) April 8, 2014 Arkansas Self Insured Association Workers’ Compensation Spring Fling (6 hours) Little Rock, AR April 16, 2014 Tools for Life, Arkansas Trauma Rehabilitation Program North Little Rock, AR (6 hours) April 17-18, 2014 Certified Brain Injury Specialist Training, Brain Injury Alliance Little Rock, AR (12 hours) May 3-4, 2014 National Expert Witness Conference Orlando, FL (12.75 hours) May 22-23, 2014 Arkansas Trauma Rehabilitation Conference Little Rock, AR (9 hours) July 31, 2014 Smart Apps for Everyday Use Brain Injury Association (1 hour) August 8, 2014 4th Annual Brain Injury Conference Hot Springs, AR (6 hours)

September 26, 2014 Health Minds, Healthy Bodies Arkansas Spinal Cord Commission Benton Event Center, Benton, AR (5.5 hours)

December 11, 2014

September 24, 2014 Success in Managing Home Modification Needs AANLCP Webinar (1 hour)

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September 30, 2014 Social Media Skills for Nursing Organizations Alliance Webinar (1.0 hour) October 16, 2014 Analysis of Nursing Home Medical Record Documentation AALNC Webinar (1.0 hour) October 17-18, 2014 5th Annual JERKCON: Following the Path to LNC Success Raleigh, NC (9.75 hours) October 23-27, 2014 AANLCP Annual Conference Atlanta, GA (17.75 hours) November 6, 2014 AALNC Unavoidable Pressure Injury Webinar (2.5 hours) November 20-22, 2014 13th Annual Fall Summit The Alliance: Nursing Organizations Alliance Tampa, FL (4.25 hours) December 11, 2014 Mindful Associations: Using Gratitude & Vision to Fuel Success Webinar (1.0 hour)

Professional Achievements Author Samples for Success: Life Care Plans from Practicing Life Care Planners. (In Press). Remington Publishing.

Minding Your Business. (2012-2013). American Association of Nurse Life Care Planners Newsletter.

Regular feature published bimonthly. Members only publication.

Powell, V. (2013). Qualifying as an Expert Witness. Journal of Nurse Life Care Planning, XIII (3).

Winter 2013.

Profiles in Case Management. (2012). (contributing author). Published August 2012 by The Healthcare Intelligence Network.

Powell, V. (2012). Cochlear implants: Interview with Two Families. Journal of Nurse Life Care Planning, XII (2). Summer 2012.

December 11, 2014

Powell, V. (2012). The Medical-Legal News. Richmond, VA. Published bi-monthly. (contributing author).

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Iyer, P., Adams, A. (2012). The Path to Legal Nurse Consulting: The Collective Wisdom of Successful Legal Nurse Consultants. (contributing author/reviewer). Published March 2012.

Powell, V. (2011). Technology for the Visually Impaired. Journal of Nurse Life Care Planning, X1 (2) Pages 408-411, Retrieved from http://www.aanlcp.org/resources/journal-archives.htm Scala, E. (2011). Learning through Experience: An Inspirational Resource Booklet of Professional Interviews, Volume III. (contributing author/nurse expert). Published February 2012.

Powell, V. (2011). Smartphones as Adaptive Technology for the Disabled. Journal of Nurse Life Care Planning, X1 (1) Pages 329-343, Retrieved from http://www.aanlcp.org/resources/journalarchives.htm Yudkoff, M., Dayanim, A., & Powell, V. (2011). Life Care Planning. P. Iyer, B. Levin, K. Ashton, V. Powell (Ed.), Nursing Malpractice: Foundations of Nursing Malpractice Claims (pp. 319-329).

Tucson, AZ: Lawyers and Judges.

Powell, V. (2011). Nursing Malpractice: Foundations of Nursing Malpractice Claims. Fourth Edition. (editor) ISBN-978-1-933264-94-3. Copyright May 1, 2011.

Powell, V. (2011). Nursing Malpractice: Roots of Nursing Malpractice. Fourth Edition. (editor) ISBN 978-1-933264-96-7. Copyright May 1, 2011.

Powell, V. (2010). Smartphone Comparison for the NLCP. Journal of Nurse Life Care Planning, X (4) Pages 294-305, Retrieved from http://www.aanlcp.org/resources/journal-archives.htm Powell, V. (2010). Nurse’s On the Run. Why They Come, Why They Stay. (contributing author). Pg. 87 “My Heart Sings.” ISBN: 978-160844-336-9. Published by Dog Ear Publishing; February 2010.

Powell, V. (2009, Dec 10). A Nurse Provides Tips for Interviewing the Disabled Person. [Web log message]. Retrieved from http://blog.reduceyourworkerscomp.com/2009/12/a-nurse-provides-tipsfor-interviewing-the-disabled-person/ Powell, V. (2009, Dec 9). Physical Ability is Major Consideration of Our Aging Workforce. [Web log message]. Retrieved from http://blog.reduceyourworkerscomp.com/2009/12/physical-ability-ismajor-consideration-of-our-aging-workforce/ Powell, V. (2009). Social Media and its use by the Nurse Life Care Planner in Marketing and Research. (E-book author) Published October 2009.

Powell, V. (2009). Partial hand amputation: a case study. Journal of Nurse Life Care Planning, IX (4) Part II, Retrieved from http://www.aanlcp.org/resources/journal-archives.htm.

Powell, V. (2009). Amputation resources and glossary. Journal of Nurse Life Care Planning, IX (4) Part III, Retrieved from http://www.aanlcp.org/resources/journal-archives.htm

December 11, 2014

Powell, V. (2009). Keeping Current in Orthotics and Prosthetics: A resource for life care planners.

Journal of Nurse Life Care Planning, IX (4) Part I, Retrieved from http://www.aanlcp.org/resources/journal-archives.htm

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Powell, V. (2009, Oct 4). 12 Steps for Employer Claims Management Using Nurse Case Management.

[Web log message]. Retrieved from http://blog.reduceyourworkerscomp.com/2009/10/twelve-steps-foremployer-claims-managment-using-nurse-case-management/ Powell, V. (2009, Oct 1). 6 Things to Address When a Field Nurse Case Manager Attends the Doctor Appointment With Injured Worker. [Web log message]. Retrieved from http://blog.reduceyourworkerscomp.com/2009/10/6-things-to-address-when-a-field-nurse-case-managerattends-the-doctor-appointment-with-injured-worker/ Powell, V. (2009, September 30). Seven Qualities You Must Have in Your Nurse Case Manager, An Insider’s Perspective. [Web log message]. Retrieved from http://blog.reduceyourworkerscomp.com/2009/09/seven-qualities-you-must-have-in-your-nurse-casemanager-by-a-nurse-case-manager/ Powell, V. (2009, September 29). Six Top Goals of Nurse Case Management from the Nurse’s Perspective. [Web log message]. Retrieved from http://blog.reduceyourworkerscomp.com/2009/09/sixtop-goals-of-nurse-case-management-from-the-nurses-perspective/ Powell, V. (2009, September 28). 22 Reasons to Refer a Claim to Nurse Case Management for Controlling Work Comp Costs. [Web log message]. Retrieved from http://blog.reduceyourworkerscomp.com/2009/09/22-reasons-to-refer-a-claim-to-nurse-casemanagement-for-controlling-work-comp-cost-control/ Powell, V. (2009, September 27). What a Nurse Says to Expect from Nurse Case Management [Web log message]. Retrieved from http://blog.reduceyourworkerscomp.com/2009/09/what-a-nurse-says-to-expectfrom-nurse-case-management/ Powell, V. (2009, September 24). A Nurse Case Manager Defines Nurse Case Management and Describes Types of Nurse Case Management. [Web log message]. Retrieved from http://blog.reduceyourworkerscomp.com/2009/09/a-nurse-case-manager-describes-nurse-casemanagement-and-types-of-nurse-case-management/ Powell, V. (2009, August 4). A Nurse Case Manager’s Tips for Working with Medical Personnel. [Web log message]. Retrieved from http://blog.reduceyourworkerscomp.com/2009/08/a-nurse-case-managerstips-for-working-with-medical-personnel/ Powell, V. (2009, August 4). Nurse Case Manager Recommends Keeping ASA, Workers’ Comp, and FMLA Separate. [Web log message]. Retrieved from http://blog.reduceyourworkerscomp.com/2009/08/the-nurse-case-manager-recommends-keeping-adaworkers-comp-and-fmla-separate/

Powell, V. (2007). Nurse Entrepreneurs: Tales of Nurses in Business (contributing author). Ch. 31 Pg. 199 “Roses are Red, Violets are Blue You Own a Company. Not One, But Two!” ISBN 09678112-3-6 Fourth edition. Published 2007.

Presentations Powell, V., Rosetti, M., Simoneaux, K. (2014). Are You Prepared for Your Testimony? AANLCP Annual Conference. Atlanta, GA. Scheduled for October 26, 2014.

December 11, 2014

Powell, V. (2009, August 3). Interview of Nurse Case Manager Her Perspective on Return to Work.

[Web log message]. Retrieved from http://blog.reduceyourworkerscomp.com/2009/08/interview-of-nursecase-management-nurse-her-perspective-on-return-to-work/

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Czarnik, B., Giles, S., Powell, V., & Thomas, C. (2014). Connecting the Dots: Understanding the relationship between Case Management and Nurse Life Care Planning. AANLCP Webinar. August 13, 2014.

Bate, B., Nelson, D., & Powell, V. (2014). Unlock the Power of AANLCP. AANLCP Webinar. July 30, 2014.

V. Powell, V. (2014). Traumatic Brain Injury: The Invisible Disability. University of Arkansas Global Campus. Rogers, AR. June 26, 2014.

Powell, V. (2014). Amputation Injury & Prosthetic Care. Arkansas Self-Insured Association. Hot Springs, AR. April 8, 2014.

Powell, V. (2014). Calculating Brain Injury Damages & Life Care Planning. In association with National Business Institute. Little Rock, AR. March 21, 2014.

Powell, V. (2013). Preconference Sessions. Restart, Refresh, Refocus. AANLCP Annual Conference.

Philadelphia, PA. November 8, 2013.

Powell, V. (2013). Medical and Legal Consequences Associated with Falls. Meet the Experts CLE. ATLA Rogers, AR. June 28, 2013.

Powell, V. (2012). Promote Yourself. NNBA Healthcare Self-Employment Entrepreneurship Summit.

Orlando, FL. August 18-19, 2012.

Powell, V. (2012). Advanced Technologies in Prosthetics. Meet the Experts CLE. ATLA. Rogers, AR. June 29, 2012.

Powell, V. (2012). Anatomy and Physiology 101 for Attorneys: Shoulder Injuries. In association with National Business Institute. Little Rock, AR. June 27, 2012.

Powell, V. (2012). Anatomy and Physiology 101 for Attorneys: Hand and Wrist Injuries. In association with National Business Institute. Little Rock, AR. June 27, 2012.

Powell, V. (2012). Anatomy and Physiology 101 for Attorneys: Knee & Spine Injuries. In association with National Business Institute. Little Rock, AR. June 27, 2012. (Presentation only. Work product by another) Powell, V (2012). Navigating Healthcare and Advocating for Your Needs. 3G Women’s Group, Midtowne Church, Benton, AR. April 16, 2012.

Powell, V. (2012). “Get the Word Out.” [Presentation]. AALNC Legal Nurse Consulting Educational and Networking Forum. San Antonio, Texas. March 29, 2012.

Powell, V. (2011). “She Blinded Me with Technology…and MSA’s.” [Webinar presentation]. Greater Augusta AALNC. November 12, 2011.

Powell, V. (2011). “On the Go…the Mobile Office and Smartphones for Business.” [Webinar presentation]. Greater Augusta AALNC. November 12, 2011.

December 11, 2014

Powell, V. (2012). “Oh! The Places You’ll Go.” [Presentation]. AALNC Legal Nurse Consulting Educational and Networking Forum. San Antonio, Texas. March 30, 2012.

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Powell, V. (2011). “Building a Winning Website: Resources for Novices to Experts in Business.”

[Presentation]. National Nurses in Business (NNBA). Orlando, Florida. November 5, 2011.

Powell, V. (2011). Anatomy and Physiology 101 for Attorneys: Shoulder Injuries. In association with National Business Institute. Little Rock, AR. June 2011.

Powell, V. (2011). Anatomy and Physiology 101 for Attorneys: Hand and Wrist Injuries. In association with National Business Institute. Little Rock, AR. June 2011.

Powell, V. (2011). Beyond the Limb [Presentation]. PrimeFare East 2011 O&P Conference. Nashville, Tennessee. June 4, 2011.

Powell, V. (2011). “Online or Left Behind: Marketing via Websites and Blogging.” [Webinar Presentation]. Med League Services and PatIyer.com. January 26, 2011.

Powell, V. (2010). Technology Best Practices. [Presentation]. National Nurses in Business (NNBA).

Orlando, Florida. November 7, 2010.

Powell, V. (2010). “Social Media Marketing for Nurses.” [Presentation]. National Nurses in Business (NNBA). Orlando, Florida. November 6, 2010.

Powell, V. (2010). “The Lifetime Care of the Amputee.” [Presentation]. October 10, 2010 in Boston, MA at AANLCP National Conference.

Powell, V. (2010). “Nurses Mean Business-Business Practices for the Nurse Life Care Planner in the 21st Century.” [Presentation]. Full day pre-conference offering. October 8, 2010 in Boston at the AANLCP National Conference.

Powell, V. (2010). “How Your Practice and Patients Benefit from Establishing Relationships with Nurse Life Care Planners; “[Presentation]. June 4-5, 2010 in Nashville, TN in association with the 12th annual PrimeFare East Regional Scientific Symposium Powell, V. (2010). “Evidence and Expert Testimony Best Practices: Supporting Your Case.” [Mock Deposition Expert & Speaker]. In association with National Business Institute. Little Rock, AR. March 24, 2010.

Powell, V. (2010). “Determining Damages in Amputation and Orthopedic Injury” [Presentation]. Medical School for Attorneys in association with the Arkansas Trial Lawyers Association. February 26, 2010.

Powell, V. (2009). “The Creative LNC-Flexibility and Innovation Required” [Presentation]. Greater Orlando Chapter of AALNC. Orlando, Florida. Scheduled but not held on October 30, 2009.

Powell, V. (2009). “Medicare Set-Aside Allocations.” [Presentation]. Arkansas Trial Lawyers Association; Personal Injury CLE Seminar. UALR Bowen School of Law. June 18, 2009.

Powell, V. (2009). “Healthcare Consumerism.” [Presentation]. Arkansas Public Library, Terry Branch, Little Rock, Arkansas. May 28, 2009.

December 11, 2014

Powell, V. (2009). “Social Media Marketing for Nurses.” [Presentation]. National Nurses in Business (NNBA). Daytona Beach, Florida. Scheduled for October 24 & 25, 2009. Cancelled.

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Powell, V. (2009). “Personal Injury Cases in Arkansas: Maximizing the Outcome.” [Presentation]. Guest speaker on Medicare Set-Asides as it applies to Personal Injury in association with National Business Institute and attorneys William C. Frye, Robert Buckalew, and Cynthia Rogers Little Rock, AR. May 18, 2009.

Powell, V. (2009). “LNC in the Role of Workers Compensation Case Management.” [Presentation].

American Association of Legal Nurse Consultants (AALNC). Phoenix, Arizona. April 25, 2009.

Powell, V. (2009). “New Technology to Grow Your Business.” [Tele-seminar]. Med League Support Services, Inc. February 4, 2009.

Powell, V. (2008). “Advanced Expert Witness Deposition Tactics.” [Mock Deposition Expert]. Guest Expert for Mock Deposition in association with National Business Institute. Little Rock, AR. December 5, 2008.

Powell, V. (2008). “Hang Your Shingle.” [Presentation]. NNBA Conference. Daytona Beach, FL. November 9, 2008.

Powell, V. (2008). “Business & Marketing Tips for Nurse Entrepreneurs.” [Presentation]. NNBA Annual Conference. Daytona Beach, FL. November 9, 2008.

Powell, V. (2008). “Personal Injury Cases in Arkansas: From Start to Finish.” [Panel discussion]. A panel discussion on Medicare Set-Asides as it applies to Personal Injury in association with National Business Institute and attorneys William C. Frye, Robert Buckalew, and Joe Morphew. Little Rock, AR. June 4, 2008.

Powell, V. (2008). “How Will ‘Medicare as Secondary Payer Act’ Affect You?” [Presentation]. Arkansas Adjuster’s Association. Little Rock, AR. May 12, 2008.

Powell, V. (2008). “Medicare Set-Aside Allocations.” [Presentation]. Baptist Health Medical Center, Little Rock, AR. April 18, 2008.

Powell, V. (2007). “Safety Concerns in an Aging Workforce.” [Workshop and presentation]. Conestoga Wood Specialties Safety Summit. Mountain View, AR September 18, 2007.

Powell, V. (2007). “Case Management, Life Care Planning and Medicare Set-Asides.” [Presentation].

Baptist School of Allied Health. Little Rock, AR. September 12, 2007.

Powell, V. (2007). “Saving $ and Making Sense of Workers Compensation Claims Management.”

[Presentation]. Benton Chamber of Commerce. Benton, AR. June 7, 2007.

Poster Presentations “Social Media and its use by the Nurse Life Care Planner in Marketing and Research.” American Association of Nurse Life Care Planners (AANLCP) Conference. Denver, Colorado. October 9-12, 2009.

Contributing Faculty Member University of Florida Forensic Science for Nurses program: http://fsn.dce.ufl.edu/instructors.shtml

December 11, 2014

Powell, V. (2007). “Interpreting Medical Information.” [Presentation]. National Business Institute. Little Rock, AR. January 29, 2007.

Index A AANLCP (American Association of Nurse Life Care Planners), 144, 237, 334–35, 348, 829, 1173–74, 1185–88, 1195–1201, 1204–5, 1212–13, 1222–23, 1228, 1235, 1238, 1245 ACA (Amputee Coalition of America), 34, 48, 134, 142, 1228 Acquired Brain Injury, 147–49, 242, 347, 1176, 1190, 1214, 1222 Alteration in Mobility, 646, 651–52, 654, 687, 693–96, 731, 738–40 amputation revision, 49, 135, 138, 140 amputations, 21, 23, 25, 32–49, 53–55, 57, 59, 73, 107–9, 119–23, 135, 137 B birth injuries, 442, 763, 765, 1180 brachial plexus injury, 52–53, 61, 65, 70–71 right, 52–53, 61–62, 66, 71–72 brain injury, 147–49, 192, 200–201, 203–4, 206, 214–17, 219–21, 224–25, 227, 237–41, 593, 603–5, 615, anoxic, 192, 194, 199, 201, 203, 211–12, 345 mild traumatic, 106, 110, 238, 240–43, brain injury support group, 214, 217, 224, 234 burn accident, 260–62, 265, 267, 269, 271, 275, 278 burn injuries, 245, 253, 259–60, 269, 294, 298, 334–37, burns, 245–47, 250, 254–55, 270, 273, 288, 290, 293–97, 299–302, 310–14, 316, 318–20, 322, 334–37, facial, 250–51, 294–95, 300 thickness, 246, 248, 253 C

counseling, 200–212, 215–16, 319–20, 322, 369, 730, 757, 807, 809, 826–27, 890, 1106, 1108, 1110–12, 1146 D deep vein thrombosis. See DVT dialysis, 816, 820, 822, 824, 1007–11, 1017–20, 1022, 1026–27, 1032–33, 1040–42, 1053–57, 1063–66, 1072–74, 1093–94, 1098–99 disorders, sleep maintenance, 766, 777–78 Down syndrome, 763, 801, 804–5, 807–11, 813– 14, 986 DVT (deep vein thrombosis), 125, 248–49, 251, 253–54, 660, 692, 702, 748, 854, 872, 877, 880–84, 887, 953–54, 979 dystonia, 351, 433–34, 442, 450, 469, 472–73, 476, 481, 485, 488–92, 504–6, 509–12, 541 E educational programs, 134, EMG, 63, 67, 71 evaluation driving, 44, 110, 118, 229, 231, 322, 881, 884 home contractor, 898–99, 902 internist, 520–22 speech therapist, 527–30 evaluation/consultation, 399–400, 403 evaluation/consultation/re-evaluation, 399–404 F Familycounseling, 556, 558, 949 FCE (Functional Capacity Evaluation), 1031, 1044, 1077, 1089, 1096, Functional Capacity Evaluation. See FCE G

cadaver skin, application of, 250–52 case management services, 30, 106, 189, 192, 292, 594, CerebralPalsy, 556–86 Cerebral Palsy, diagnosis of, 352, 459, 776 Cerebral palsy (CP), 339, 345, 349–59, 369–71, 375–79, 441–43, 447–51, 461–63, 467–69, 489–91, 535–39, 541–43, 545–47, 587–91, 829–31 child psychologist, 1030–31, 1076–77 chronic pain specialist, 196, 207, 210 contractures, 78–103, 178, 256–57, 277, 283, 299, 302, 304, 444, 494, 497, 603, 607–8, 613–14, 865 Cost Resource, 123, 125, 127, 129–33, 139, 141, 277, 645–46, 648–49, 686–88, 690–91, 907, 909

GMFCS (Gross Motor Function Classification Scale), 339, 350 Gross Motor Function Classification Scale (GMFCS), 339, 350 group home, 154–55, 159, 811 H headaches, 73, 184–85, 198, 210, 636, 677, 721, 819, 844, 893, 1010, 1023–24, 1056, 1069– 70, 1145 migraine, 183, 185, 216, 636, 677–78, 721–22, 1145 head injury, 71, 109, 119, 137, 209, 224, 239, 339, 440–41, 877, 879 mild, 122–35

heart transplant, 987, 1100, 1103–4, 1107, 1111– 12 Hemiparesis, 630, 645–60, 662, 686–702, 705, 730–48, 766 left, 776, 778, 787, 790 hemodialysis, 253, 819, 988, 1016–18, 1020, 1062–64, 1066 HHA, live-in, 159, 758 HHA (Home Health Aide), 149, 159, 180, 189, 385, 536, 549, 614, 669, 712, 758, 799, 811, 919, 1109 home assessment, 162, 180, 357, 627, 1141 home care, 45, 133, 148, 313, 378, 386, 540, 614, 656, 698, 717, 787–88, 814, 998, home contractor, 876, 888, 898 home dialysis, 1008, 1010–11, 1024, 1026, 1054– 55, 1057, 1070, 1072, 1093 home evaluation, 133, 223, 233 home health, 255, 277, 360–61, 364, 633, 657, 666, 670, 699, 709, 713, 717, 744, 971 home health aide, 149, 180, 189, 536, 549, 614, 669, 712, 758, 919, 1109 Home Health Aide. See HHA home hemodialysis, 1024, 1027, 1070, 1074 home maintenance, 46, 267, 286, 656–57, 698– 99, 743–44, 895, 897, 991–92, 1109, 1159 home modifications, 46, 270, 286, 344, 359, 368, 627, 755, 758–59, 835, 876, 888, 898–99, 973, 1152 Home OT evaluation, 887, 899, 906 I IEP (individualized education plan), 464, 469–70, 549, 764, 782–85, 789–90, 792–93, 795, 797–99 Impaired Home Maintenance, 45, 919, 1144 Impaired Memory, 157–59, 187–89, 220, 226–32, 234, 673, 716 Impaired mobility, 34, 40–41, 118, 120, 130, 137, 284–85, 323, 591–92, 661, 695, 704, 914– 15, 917–20, 968 Impaired Physical Mobility, 131–32, 158, 220, 226, 228–29, 231, 235, 319, 329, 689, 694, 733, 739, 756–58, 865 Impaired Skin, 38, 129, 328, 654, 696 impaired skin integrity, 129, 131, 140, 175, 283, 319, 322, 326, 693–94, 738–39, 741 increased tone, 447, 449–50, 453–56, 466–67, 481, 483, 485–86, 488, 492–94, 497–98, 541, 543, 599–600, 775–76, 791–92 injury, incomplete, 660, 702, 748 International Society for Burn Injuries, 336–37, 1195 K

kidney transplant, 816, 819, 822, 1001, 1006, 1008, 1011–12, 1020, 1022–23, 1047, 1054, 1057–58, 1066, 1068–69, 1073–74 kidney transplantation, 1020–21, 1066–67 knee amputation, 21, 106–7, 113, 122–36, 138–40 L language development expressive, 773–74, 783, 789 receptive, 773–74, 783, 789 LCP Stat, 1245 LifeExpectancy, 86, 88, 164, 166, 168, 170, 172, 174, 176, 178, 389, 572, 946–82 lung transplant, 987, 989–92, 994 M maintenance, 43, 45–46, 74–75, 158, 286, 652– 55, 695–97, 740, 860–62, 867–68, 895, 914– 15, 943–44, 1080–81, 1157 yard/home, 270, 656, 698, 743, 899, 974 maintenance/repair, 917–18, 920 MCP. See Medical Cost Projection Medical Cost Projection (MCP), 11–14, 164, 1119, 1141, 1152 Medical Cost Projection (MCP)., 12 medical cost projections, 9, 1119, 1141, 1152, Medical Timeline, 195–96, 249–50, 259, 878, 889, 926 Mobility/Maintenance, 333, 567–69, 582 MRSA (Methicillin-Resistant Staphylococcus Aureus), 66, 253–54, 433–35, 489–90, 843, 925, 934, 947–48 muscle atrophy, 629, 637, 645–61, 678, 686–702, 704, 722, 730–48 muscle tone, 437, 443, 446, 455, 483, 485–86, 495, 507–8, 510–12, 543, 660, 702, 748, 785 N neuritis, 629, 645–61, 686–702, 704, 730–48 neuropathic pain, 71, 300, 311, 631, 650, 660, 664, 676, 692, 702, 707, 721, 736, 738, 748 nursing home, 162–63, 329, 643, 684, 729, 974 P pain complain of, 632, 665, 708 intractable, 70, 634, 668, 670, 711, 713 pain control, 64, 246, 514, 631, 633, 645, 664, 666, 686, 707, 709, 930

pain management, 67, 70, 186–87, 190, 197–98, 256–57, 319–21, 649, 667, 691, 710, 712, 735, 753, 756 pain management specialist, 64, 311, 753, 756 pain radiating, 63, 75, 632, 665, 708 Pediatric Dentistry, 461, 463–64, 473–74, 478, 490, 502, 514, 517–19 Pediatric Neurology, 439, 441, 443, 446, 455–56, 469–70, 472–73, 476, 480, 482, 484, 487, 490, 492, 507 Pediatric Otolaryngology, 500–502, 509, 518 PersistentVegetativeState, 164, 166, 168, 170, 172, 174, 176, 178 positioning devices, 495, 503, 506–8, 511 Post Traumatic Stress Disorder. See PTSD power chair, 632, 637–38, 640–42, 647, 678, 680– 82, 684, 689, 717, 722, 724–26, 728, 733, 1035, 1080 power wheelchair, 428, 478, 481, 483, 505, 507– 8, 550, 942 prosthesis, 21–22, 26–27, 43, 45, 49, 74, 106, 118, 131, 135, 138, 140, 835 psychological evaluations, 254, 301, 311, 795, 931, 949, 1011, 1057 PTSD, diagnosis of, 205, 268 PTSD (Post Traumatic Stress Disorder), 122–35, 201–2, 204–7, 210–12, 247–48, 252, 262, 299, 302, 307, 310–11, 313, 315, 319–20, 1217–18 R RECREATION, 652, 695, 740 renal transplant, 822, 1016–17, 1022, 1062–63, 1068 rental homes, 308, 349, 354, 894, 897–98, 919 respite services, 444–45, 478–79, 484, 490, 669, 712 Risk for Disuse, 653, 695, 740 Risk for Electrolyte Imbalance, 822, 825, 1107–8 Risk of powerlessness, 229–32 S scar management, 259–60, 269, 278, 283, 286, 289 SCI. See spinal cord injury SCIRE (spinal cord injury rehabilitation evidence), 984–85 Self-Care Deficits, 286, 321, 323, 646–47, 652, 656, 687, 689, 693–94, 698, 731, 738–39, 744, 756–58, 914 severe pain, 72, 74–75, 296, 306, 627, 677, 721, 749, 753 Shepherd Center, 841, 877, 879, 882, 884–87, 889–90, 899, 903, 905, 920–21, 952, 1244

shoulder pain, 69, 75, 835, 844, 885, 889, 893– 94, 901, 1015, 1061, 1146 skin grafting, 246, 248–49, 283 SLP (Speech-language pathology), 356, 359, 368, 600, 603, 783, 789, 793 spasticity, 351–52, 456–57, 468–70, 472–73, 480, 484–85, 487–88, 511–12, 540–42, 593–94, 599–602, 606–8, 615, 835–36, 977 dynamic, 541, 543–45 Speech-language pathology. See SLP spinal cord injury (SCI), 748–49, 833–35, 840–42, 849–52, 854–55, 872–73, 875–77, 879–81, 889–90, 894–95, 942–44, 975–80, 984–86, 1243–44 spinal cord stimulator trial, 634, 668, 711 T T-5 Paraplegia, 946–82 TBI. See traumatic brain injury TBSA (total body surface area), 248, 250, 253, 280, 283, 286, 288, 290, 294 total body surface area. See TBSA transplant, 816, 819, 821–25, 987–89, 992–94, 997–99, 1011–12, 1026–27, 1032–33, 1057– 58, 1072–74, 1100, 1106, 1111–13, 1115 traumatic brain injury (TBI), 52–53, 70, 147–48, 180, 183, 185, 237–43, 588, 590–91, 593– 95, 612, 831, 986, U UV protectant clothing, 260, 283 V VAD (ventricular assisted device), 1100, 1106–7, 1109–10, 1113 vehicle modifications, 33, 886, 949, 951 ventricular assisted device. See VAD vision loss, 308, 1117–18, 1142, 1144, 1147–49, 1152, 1243–44 vocational assessment, 47, 293, 316, 595, 629– 30, 661–62, 704–5, 1142–43, 1181 W Wheelchair and Mobility, 1005, 1007, 1029, 1035, 1051, 1053, 1075, 1080 Wheelchair Evaluations, 510, 613, 851, 917, 949–50, 967