Coping with illness 11-1-07

© Copyright 2007 - LifeSan Care Management, LLC

www.LifeSpanCM.com

Health Coordination & Advocacy

Coping With Serious Illness:Strategies for Individuals &

FamiliesNational Caregivers Convention

Michael Newell, RN, MSNLifeSpan Care Management, LLC


www.LifeSpanCM.com


Who is LifeSpan

A hand-picked group of health professionals who know how the system works and how to work the system in your best interest.

Experts trained in making connections and resolving the issues that stand between patients and their optimal state of health as they and their family would define it.


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A Broken System:Hospital Deaths: 100,000 per year to mistakes, 100,000 to infections...etc.

Adverse Drug Events (ADEs) rampant– Resulted in 4.3 million outpatient visits in 2001, half

required ER 2.1 million to those over 64 years old– Barely 2% reported!High waiting times in doctor office, with not enough time to speak to himSee the doctor for 7 minutes in a typical hospital stay


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The Cost of Chronic Disease

More than 90 million Americans live with chronic illnesses.Chronic diseases account for 70% of all deaths in the United States.The medical care costs of people with chronic diseases account for more than 75% of the nation’s $1.4 trillion medical care costs.Chronic diseases account for one‐third of the years of potential life lost before age 65.


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Has Allopathic Medicine Has Lost Its Moral Voice?

The Medical‐Industrial Complex works for them, not us…– Vioxx, malfunctioning pacemakers & internal

defibrillators, estrogen therapy, doctors on the take…etc.

55% get the “proper medical care”Drugs work < 60% of the timeAntidepressants work ~50% of the timePlavix benefits (the #2 selling drug in the world) are offset by death rates due to GI bleeding


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Normal Aging Process has ChallengesWhen You Are Not Safe,

You Lose Your VoteFree Advice Is Usually WorthlessUnderstand the natural course of the disease process Contingency Plans Should Support Parent and Family

RecognizeProblems Early


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Safety IssuesThreaten Autonomy

Test for Safety:– Medication– Arising From Sitting Position– Ambulation– Stairs– Home SurveyPhysician Has “Duty To Report” Unsafe Drivers


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Contingency Plans

Plan A: Do nothingRisk: Catastrophic

injury/illness/deathLoss of choice: No Living

Will/POAAssisted Living $4500+/monthNursing Home $7000+/monthLoneliness/Guilt/Recrimination


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Evaluate Options: $695Medical and Financial Power of Attorney: $350+Ongoing Care Coordination: $165/hour– Save missteps on medical treatment

plan– Keeps loved one independent– Avoids conflict within family– Reduces stress & fear of unknown– Saves time & money

Plan B: Care Management


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Reasons to Engage Health Advocates

Moderated Group/Family MeetingNegotiations are “Transparent’Use Hearing/Listening TechniquesPlan of (Care) Action options are flexible and responsive to changesAccount for Cultural/Spiritual Preferences of the FamilyCost Efficient/Effective


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Understanding the SystemHelps Resource Access

Self

Family

Medical System

Insurance Systems

Social Service Systems


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The SelfThe Body System

The course of Chronic DiseaseHydration & NutritionMental Alertness

Emotional System:Energy Vs. Fatigue (Depression?)Quality of “self-talk”

Spiritual SystemWhat Do We Live For?Ongoing Spiritual Practices?


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The Path of Chronic Disease


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Human Responseto Stress

AlarmResistance Exhaustion

Stress is the body’s response to noxious stimuli. The longer the stress event, the more severe the response.


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The General Adaptation Syndrome

Hans Selye

Alarm

Resistance

Exhaustion


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Response to Illness: Loss

Loss of sense of well-being

Loss of function

Loss of role in family

Loss of energy

Loss of job

Loss of self-esteem


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On Death and DyingElizabeth Kubler-Ross

Denial

Bargaining

Depression/Fatigue

Resolution

Anger/Arousal

The stages of of loss…


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Tweaking the Bell Curve


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The Meaning of IllnessChallengeStrategyEnemy to be ResistedWeakness/Character FlawDeserved Loss/PunishmentGod’s WillRelief


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Family SystemsAssumed Source Of Support

Hindered by Geography, Time Constraints, Authority Issues, Past Hurts

Wider Social Support Systems Are Also Effective

Church Groups, Social Groups, Problem –Focused Support Groups


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Choosing a Doctor

MD vs. DOSpecialist vs. GeneralistBoard CertificationHospital affiliationWhen surgery is proposedFollow‐up careAlternative Treatment Providers


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Constructing A Life Care Plan

Total

Medication

Soft goods

Equipment

Nursing care

CostItem DetailPurpose


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Setting Goals:Functional Independence Measures

Uniform Data Set for Medical Rehabilitation @ SUNY, Buffalo, NYDiscipline‐free/statistically validatedData collection in a consistent fashionDocuments severity of disability in relation to “burden of care”Tracks resource uses in physical, social and substituted time and energy modes


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Theoretical Basis for the FIM

Impairment: Abnormalities of structure or function. Disturbances at organ levelDisability: Abnormality at person level. Restrictions of compound integrated activities‐‐tasks, skills and behaviors.Handicap: Prevents the individual from fulfilling a role that is normal for that individual. A Handicap reflects the cultural, social or economic consequences of impairment or disability. Handicap is shaped by values and attitudes.– Source: World Health Organization


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Domains of the FIMCOGNITION

ComprehensionExpressionSocial InteractionProblem SolvingMemory

SELF-CAREGrooming BathingDressing Upper BodyEatingDressing Lower BodyToiletingBladder ManagementBowel Management

MOBILITYTransfers

Chair, Wheelchair

ToiletTub, Shower

LocomotionWalk, Crawl,

WCStairs


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FIM Decision Tree7: Complete Independence Client completes activity

without help, assistive device, in a reasonable time and without safety concerns

6: Modified Independence Needs more time, assist device or safety concerns

5: Supervision Needs set-up, cueing or contact guarding

4: Minimal Assistance Completes 75-100% of task

3: Moderate Assist Completes 50-75% of task

2: Maximal Assist Completes 25-50% of task

1: Total Assist Completes little or none by self


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A Rehab Worksheet that Everyone Can Understand

TOTAL SCORESocial InteractionExpressionProblem solvingComprehensionWalkingTransfer toiletTransfer chair/WCBowel mgt.Bladder mgt.ToiletingDressing BathingEating

STRATEGY TO MEET THE GOALSGOALSCOREDOMAIN


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Insurance Systems

Auto has $250,000 cap on “PIP”– Strong rehab reimbursement tradition Workers’ Compensation– Pays all health costs, wage loss– Treatment “directed” by insurance company– Goal is to reach “MMI”Managed Care– Stringent access– Don’t believe in rehab


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Sample of Insurance Coverage Appeal

Construct a Life Care PlanFind out what other payment resources are availableReview Insurance Policies carefullyGather supporting documentsWrite appeal letters within time frameDon’t give upSeek experienced attorney


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Aetna Appeals ProcessSpelled out in “Master Contract” & “Clinical Policy Bulletins”Denials for urgent or concurrent care answered within 36 hours for Level 1 & 2Pre‐cert denials within five business days for Level 1, 15 days for Level 2External Appeals after other appeals go to NJ Department of HHS who contracts with Independent Utilization Review Organization


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36,000$3,000 per month

Use daily as needed

Sterile WaterPeroxideAlcohol prepsIrrigation trayUrine bagTapeSuction cathetersBreathing circuitsYankauerTrach kitGlovesGauzeCanisterNebulizer kit, etc.

Equipment & medical supplies(Assumes ventilator rental included)

446,760Projected:Aetna $385,560

School61,300

Aetna= 87% or avg 20.5 hr/daySchool=13%

Hands on care, estimated 80% by RNs, 20% by LPNs at a price of $52/hr for RNs, $47/hr for LPNs (blended rate=$51/hr)Average 7.5 hours per school day covered by XXX School District for an estimated 160 days per year

Skilled Nursing Care

Total/yrcostsFrequencyItems/ServiceCare Needs


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$554,700Insurer, school district and familyTotal all costs

$3,700Total Family

113,955Excluding testing, instructional, CM, etc.Therapy $48,930, skilled nursing: $65,025

Total of school district costs

$3,900320/m$10.66/dDetailed med costsMedication

3,000~ $600

5 x yearPresently approximately, avg. cost estimated:

Ambulance [4]

1,000Van costs estimate at $.50 mile x 2000 m/year

Transportation

T$63,330Aetna

14,400

Aetna =$1200/m

11 weekly sessions @$120/hour

PT and OT 3 x weeklySpeech therapyCognitive rehabilitation therapy daily for one hour

Rehabilitation, including cognitive therapy[3]

2001002 x yearMaintenance. Expected life 7-8 yearsVan Lift

$2,5004 x/yrPlus phone support

To evaluate and quality control the nursing care,

Private Care Manager[2]

1110[1]32020018090160

4 x year2 x year2 x year1 x year2 x year

Primary CareOphthalmologistPulmonologistUrologistOrthopedist

General medical care


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AETNA COSTS

Savings to Aetna per month: $6285, per year $75,420

$42,940Plus estimated ambulance charges ($3,000 per year, $250/month)

$42,690Amount now paid by Aetna for inpatient care alone (September 2006)

$36,655Total per month$439,860Total

14,400Therapies3,900Medication

36,000Equipment & supplies, including respiratory385,560Skilled Nursing


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Medicare/Medicaid

Medicare pays for first 20 days and a portion of 100 days of post-hospital rehabilitation services

Medicare Home Health Services are used to maintain a person in the home

An appropriate referral for this service Is a “willing and able” caregiver in the home


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Alternative Funding Sources

Review available Ins. coverage

Coordination of Benefits rules

EntitlementsMedicare

Medicaid

Medicaid Waiver & Model Waiver

Children’s Catastrophic FundVeterans Benefits


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Thank You!

For more information, contact:

Michael Newell, RN, MSN, [email protected]

1-800-808-9844

Coping with illness 11-1-07

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