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 &
Families
National Caregivers Convention
Michael Newell, RN, MSN
LifeSpan 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.

www.LifeSpanCM.com
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 him
See the doctor for 7 minutes in a typical hospital
stay

www.LifeSpanCM.com
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.

www.LifeSpanCM.com
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 time
Antidepressants work ~50% of the time
Plavix benefits (the #2 selling drug in the
world) are offset by death rates due to GI
bleeding

www.LifeSpanCM.com
Normal Aging Process has Challenges
When You Are Not Safe,
You Lose Your Vote
Free Advice Is Usually Worthless
Understand the natural course of the
disease process
Contingency Plans Should Support
Parent and Family
Recognize
Problems Early

www.LifeSpanCM.com
Safety Issues
Threaten Autonomy
Test for Safety:
– Medication
– Arising From Sitting Position
– Ambulation
– Stairs
– Home Survey
Physician Has “Duty To
Report” Unsafe Drivers

www.LifeSpanCM.com
Contingency Plans
Plan A: Do nothing
Risk: Catastrophic
injury/illness/death
Loss of choice: No Living
Will/POA
Assisted Living $4500+/month
Nursing Home $7000+/month
Loneliness/Guilt/Recrimination

www.LifeSpanCM.com
Evaluate Options: $695
Medical 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

www.LifeSpanCM.com
Reasons to Engage
Health Advocates
Moderated Group/Family Meeting
Negotiations are “Transparent’
Use Hearing/Listening Techniques
Plan of (Care) Action options are
flexible and responsive to changes
Account for Cultural/Spiritual
Preferences of the Family
Cost Efficient/Effective

www.LifeSpanCM.com
Understanding the System
Helps Resource Access
Self
Family
Medical System
Insurance Systems
Social Service Systems

www.LifeSpanCM.com
The Self
The Body System
The course of Chronic Disease
Hydration & Nutrition
Mental Alertness
Emotional System:
Energy Vs. Fatigue (Depression?)
Quality of “self-talk”
Spiritual System
What Do We Live For?
Ongoing Spiritual Practices?

www.LifeSpanCM.com

www.LifeSpanCM.com
The Path of Chronic Disease

www.LifeSpanCM.com
Human Response
to Stress
Alarm
Resistance
Exhaustion
Stress is the body’s response to
noxious stimuli. The longer the
stress event, the more severe the
response.

www.LifeSpanCM.com
The General Adaptation Syndrome
Hans Selye
Alarm
Resistance
Exhaustion

www.LifeSpanCM.com
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

www.LifeSpanCM.com
On Death and Dying
Elizabeth Kubler-Ross
Denial
Bargaining
Depression/Fatigue
Resolution
Anger/Arousal
The stages of of loss…

www.LifeSpanCM.com
Tweaking
the Bell Curve

www.LifeSpanCM.com
The Meaning of Illness
Challenge
Strategy
Enemy to be Resisted
Weakness/Character Flaw
Deserved Loss/Punishment
God’s Will
Relief

www.LifeSpanCM.com
Family Systems
Assumed 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

www.LifeSpanCM.com
Choosing a Doctor
MD vs. DO
Specialist vs. Generalist
Board Certification
Hospital affiliation
When surgery is proposed
Follow‐up care
Alternative Treatment Providers

www.LifeSpanCM.com
Constructing A
Life Care Plan
Total
Medication
Soft goods
Equipment
Nursing care
CostItem DetailPurpose

www.LifeSpanCM.com
Setting Goals:
Functional Independence Measures
Uniform Data Set for Medical Rehabilitation @
SUNY, Buffalo, NY
Discipline‐free/statistically validated
Data collection in a consistent fashion
Documents severity of disability in relation to
“burden of care”
Tracks resource uses in physical, social and
substituted time and energy modes

www.LifeSpanCM.com
Theoretical Basis
for the FIM
Impairment: Abnormalities of structure or
function. Disturbances at organ level
Disability: 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

www.LifeSpanCM.com
Domains of the FIM
COGNITION
Comprehension
Expression
Social Interaction
Problem Solving
Memory
SELF-CARE
Grooming
Bathing
Dressing Upper Body
Eating
Dressing Lower Body
Toileting
Bladder Management
Bowel Management
MOBILITY
Transfers
Chair,
Wheelchair
Toilet
Tub, Shower
Locomotion
Walk, Crawl,
WC
Stairs

www.LifeSpanCM.com
FIM Decision Tree
7: 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

www.LifeSpanCM.com
A Rehab Worksheet that
Everyone Can Understand
TOTAL SCORE
Social Interaction
Expression
Problem solving
Comprehension
Walking
Transfer toilet
Transfer chair/WC
Bowel mgt.
Bladder mgt.
Toileting
Dressing
Bathing
Eating
STRATEGY TO MEET THE GOALSGOALSCOREDOMAIN

www.LifeSpanCM.com
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

www.LifeSpanCM.com
Sample of Insurance
Coverage Appeal
Construct a Life Care Plan
Find out what other payment resources
are available
Review Insurance Policies carefully
Gather supporting documents
Write appeal letters within time frame
Don’t give up
Seek experienced attorney

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

www.LifeSpanCM.com
36,000$3,000
per month
Use daily as
needed
Sterile Water
Peroxide
Alcohol preps
Irrigation tray
Urine bag
Tape
Suction catheters
Breathing circuits
Yankauer
Trach kit
Gloves
Gauze
Canister
Nebulizer kit, etc.
Equipment &
medical
supplies
(Assumes
ventilator
rental
included)
446,760Projected:
Aetna
$385,560
School
61,300
Aetna= 87% or
avg 20.5 hr/day
School=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

www.LifeSpanCM.com
$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$63,330
Aetna
14,400
Aetna
=
$1200
/m
11 weekly
sessions
@$120/hour
PT and OT 3 x weekly
Speech therapy
Cognitive rehabilitation therapy daily for one
hour
Rehabilitation,
including
cognitive
therapy[3]
2001002 x yearMaintenance. Expected life 7-8 yearsVan Lift
$2,5004 x/yr
Plus phone
support
To evaluate and quality control the nursing
care,
Private Care
Manager[2]
1110[1]320
200
180
90
160
4 x year
2 x year
2 x year
1 x year
2 x year
Primary Care
Ophthalmologist
Pulmonologist
Urologist
Orthopedist
General medical
care

www.LifeSpanCM.com
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
14,400Therapies
3,900Medication
36,000Equipment & supplies, including respiratory
385,560Skilled Nursing

www.LifeSpanCM.com
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

www.LifeSpanCM.com
Alternative Funding
Sources
Review available Ins. coverage
Coordination of Benefits rules
Entitlements
Medicare
Medicaid
Medicaid Waiver & Model Waiver
Children’s Catastrophic Fund
Veterans Benefits

www.LifeSpanCM.com
Thank You!
For more information, contact:
Michael Newell, RN, MSN, CCM
mnewell@LifeSpanCM.com
1-800-808-9844

Coping with illness 11-1-07

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

En vedette

En vedette (8)

Similaire à Coping with illness 11-1-07

Similaire à Coping with illness 11-1-07 (20)

Coping with illness 11-1-07