Our highly credentialed vocational rehabilitation and life care plan experts write about topics that are important and relevant to our areas of practice. If you have a vocational or life care planning topic you would like to learn more about, please contact us to request a blog post on that topic.

Guest User 12/14/22 Guest User 12/14/22

Attendant Care in Life Care Planning

When developing a life care plan for catastrophic injuries, attendant care may be warranted and recommended by a treatment provider to bridge the gap of functionality caused by the indexed incident. There are tiers of attendant care depending on the patient's level of need, and it is helpful to understand the services each provider can appropriately provide. Each level of care will have a different impact on the overall lifetime cost in a life care plan. See below from least to most involvement:

Personal Care Aide (PCA)/Caregiver:
Educational requirements: none
Training requirements: varies by state (some states have no requirements)
Work setting: typically, within the homes of individuals
Duties: assistance with activities of daily living (ADLs), light household chores including meal preparation, accompaniment to doctors' appointments

Home Health Aide (HHA):
Educational requirements: none
Training requirements: minimum of 75 hours depending on the state plus certification exam
Work setting: typically, within the homes of individuals
Duties: ADL assistance, measures and charts vital signs, administers medications, wound care, etc.

Certified Nursing Assistant (CNA):
Educational requirements: high school diploma/GED
Training requirements: minimum of 75 hours depending on the state plus the passing of certification exam
Work setting: typically within nursing/residential care facilities and medical facilities
Duties: ADL assistance, communicates/alerts emergencies to nurses, measures and charts vital signs, tends to equipment such as pumps, dressings and catheters, etc., works under the supervision of a registered nurse (RN) or nurse practitioner (NP).

Licensed Practical Nurse (LPN):
Educational/training requirements: high school diploma/GED plus graduation from an accredited LPN program and passing of NCLEX-PN exam
Work setting: typically within residential care facilities and medical facilities, and in-home health
Duties: measures and charts vital signs, wound care, administers medications/injections/immunizations, tube feedings, etc., and works under the supervision of RNs, NPs, physicians, or other superior figures depending on state requirements.

Registered Nurse (RN):
Educational/training requirements: at least an associate degree plus the passing of NCLEX-RN
Work setting: typically, nursing care and medical facilities
Duties: administers medications and treatments, creates and maintains medical records, and oversees and collaborates with other treatment professionals when/as applicable.

As educational, training, credentialing, and task requirements increase, so do the costs of services. According to the U.S. Bureau of Labor Statistics 2021, national hourly rates for PCAs and HHAs range from $10.72 to $17.79 per hour. For CNAs, hourly rates range from $11.48 to $21.27 per hour. For LPNs, hourly rates range from $17.86 to $30.67 per hour. For RNs, hourly rates range from $28.58 to $58.71 per hour.

When a treating physician recommends attendant care, the life care planner will confirm the level of care needed, the required hours per day of assistance, and if the number of hours per day would increase with age/time. In addition to the life care planner consulting with the treating physician concerning attendant care, a clinical evaluation with the evaluee (or another individual who can speak on their behalf) is essential to understand their limitations and subsequent needs to determine the level of care that is appropriate.

Guest User 11/19/22 Guest User 11/19/22

Loss of Earning Capacity Versus Economic Loss

Typically, vocational rehabilitation counselors are engaged to assess loss of earning capacity following an injury. However, in some cases, earning capacity may not be the best measure of damages when assessing work and the ability to earn. For example, vocational rehabilitation counselors may have to take a different approach when assessing economic damages for business owners. John Doe owns his own scrap metal business. Before his injury, he could perform all of his business's essential job duties, including managerial responsibilities and heavy manual labor (processing metal machine parts). Following a motor vehicle collision, John was restricted to a light physical demand level and subsequently hired a laborer to perform the heavier aspects of the business. He has continued to run the company, and his 1040-Schedule Cs show that his business profits remain unchanged. The vocational rehabilitation counselor must now consider the additional cost of labor versus the profitability of John's business (i.e., earning capacity). While John's company is not losing profitability due to his injuries, he is incurring a higher cost to own and operate his business and maintain profits. If John is the company's sole owner, this extra expense directly impacts his income. Similarly, if additional equipment or supplies are needed to keep the company's profitability related to the indexed injuries, these items would also be considered compensable damages.

Vocational rehabilitation counselors need to approach each claimant's vocational situation individually, and work to determine the appropriate metrics to measure economic losses.

Guest User 10/15/22 Guest User 10/15/22

Neuropsychological Evaluations in Life Care Planning

Life Care Planning for individuals with a suspected brain injury requires specific information about residual functioning, cognitive deficits, and expected course of rehabilitation to help determine future medical, cognitive, emotional, and supportive care. Physicians commonly request neuropsychological evaluations for diagnostic and treatment planning purposes, which can be crucial in preparing a Life Care Plan.

Neuropsychological evaluations are typically performed by board-certified neuropsychologists and can take many forms. It is common to see brief neurocognitive screenings done earlier in a patient's recovery to set a baseline while the individual may still be healing from neuro-insult. These quickly administered screening tools include the Mini-Mental State Exam, the Cognistat family of tests, or the Montreal Cognitive Assessment (MoCA). Allied health professionals can administer them. Due to their brief nature, it is customary to readminister these measures to chart improvement with active care.

Once an individual with a brain injury has stabilized medically, it is common to see comprehensive test batteries administered by a board-certified neuropsychologist. The typical exams include reviewing available medical records, clinical interviews with patients and family members, and psychometric tests. For example, test batteries may consist of personality measures, intelligence testing, memory testing, tests of attention and concentration, manual dexterity tests, and others. This comprehensive assessment aims to confirm organic injury's presence (or absence) and identify emotional and psycho-behavioral issues affecting functioning. Results of the neuropsychological evaluation allow the ordering physician or the neuropsychologist to recommend cognitive rehabilitation/therapy, inpatient/outpatient neurorehabilitation treatment, financial management services, case management services, household assistance, attendant care, and/or additional neuropsychological evaluation/testing.

Neuropsychological evaluations can benefit vocational rehabilitation counselors when considering whether an individual can return to work in the occupation they held at the time of their injury, work in alternate occupations, or work with or without accommodations. The information reported in a neuropsychological evaluation addresses issues related to the mental capacity to perform work-related tasks, including interacting appropriately with the public, meeting deadlines and completing assignments, maintaining attention and concentration for extended periods, and responding appropriately to changes in the work setting.

Overall, neuropsychological evaluations can provide a rich data set for diagnosing neurocognitive functioning, tracking improvement with recommended treatments, and forecasting likely future medical and vocational needs.

Guest User 9/24/22 Guest User 9/24/22

CRPS and Life Care Planning

A life care plan (LCP) is a dynamic document based on published standards of practice, assessment, and research that outlines future needs and costs for individuals with catastrophic injuries or chronic health needs. Developing a plan for individuals diagnosed with Complex Regional Pain Syndrome (CRPS) can be challenging, as physicians’ opinions on the most effective treatment plans for CRPS can vary greatly.

CRPS is a form of chronic pain that typically involves the arms and legs and develops following an injury. The pain is generally out of proportion to the severity of the initial injury and may spread from its source to other parts of the body. Many people with CRPS describe burning and throbbing pain, sensitivity to touch, swelling, changes in skin temperature, color and texture, joint stiffness, and atrophy.

Before developing a life care plan, life care planners should carefully review all available medical records, paying particular attention to recommendations offered by treating physicians and consulting medical examiners. When consulting with physician(s) to obtain their opinions on future care needs, the life care planner should be aware of different treatment options that should be discussed during consultation.

Treatment options currently being recommended for CRPS are typically multi-faceted. They may include medication, physical therapy, nerve blocks, epidural steroid injections, platelet-rich plasma injections, stem cell injections, radiofrequency ablation of the painful sensory nerves, neurostimulation, and infusion therapies. It is also important to consider psychological factors often experienced by people with CRPS, as psychotherapy or psychiatric treatment may be warranted. Anxiety and depression are often common psychological/psychiatric diagnoses associated with CRPS.

Life Care Planners can also look at the literature to understand the typical treatment needs of those with CRPS. When using published research, it is vital to ensure that the studies or publications involve a sufficient sample size of study participants who closely resemble the demographic qualities of the subject with CRPS, and information regarding frequency, duration, and probability of occurrence would be beneficial.

Guest User 8/6/22 Guest User 8/6/22

Probable vs. Possible Costs in Life Care Planning

Life Care Plans are designed to present information regarding anticipated medical expenses throughout one’s life expectancy. These costs are calculated and based on “today’s dollars.” They have not been adjusted to include factors such as inflation or discounted value, usually the purview of a forensic economist or CPA.

Generally, a probable vs. possible level of medical certainty must be met for an item/recommendation to be included in a life care plan. Probable recommendations are determined to have a greater than 50% chance of being medically needed and thus likely to be incurred within an individual’s lifetime. Possible recommendations cannot be determined on a more probable than not basis. These items are usually stated as “may, possibly, or if” statements by the treating or consulting health care providers. Once recommendations have met the inclusion criteria, cost research can be conducted to reflect usual and customary charges for the identified care. If the treatment or service does not meet the criteria for inclusion, they are not included in the life care plan.

Although possible recommendations and costs should not be included within a life care plan, it is often helpful to acknowledge these treatment possibilities in some instances. For example, suppose the final course of care has not yet been determined at the time of trial or deposition. In that case, it may be helpful for the trier(s) of fact to have information regarding future costs associated with each treatment option being considered. Although the costs for possible treatment and services are not included in a life care plan, these costs are typically researched for “informational purposes only.” The life care planner can present the information to assist the court if treating or consulting physicians change their opinions between their deposition and trial testimony. It is incumbent on the testifying life care planner to reiterate that the informational costs are not included in the life care plan summary totals but are presented for the above contingencies.

Guest User 7/26/22 Guest User 7/26/22

Determining Work-Life Expectancy: A Case Study

Vocational rehabilitation counselors are often engaged to assist attorneys in determining pre-injury and post-injury earning capacity. Work-life expectancy is central to determining earning capacity, or the average number of years an individual participates in the labor force. Work-life expectancy estimates can help calculate final numbers for litigation or settlement purposes; however, the available research regarding work-life expectancy is outdated. The United States Department of Labor/Bureau of Labor Statistics uses research from 1986, and the Markov Model of Labor Force Activity utilizes research from 1997 to 2004. The vocational rehabilitation counselor must determine if the available resources are valid and reliable in today's job climate, where many individuals choose to work longer than retirement age.

For example, work-life expectancy was the issue in Barto v. Shore Construction (2015). The plaintiff reported that he had planned on retiring at age 67; however, the defense argued that this was greater than the average work-life expectancy for a seaman, and there was no indication that he could have worked until that age. The defendant contended that an individual's work-life expectancy cannot be based solely on their report and that other factors must be considered. The defendant further argued that an individual's work-life expectancy should be based on the average number of years an individual both works and lives and should consider elements such as an individual's health and occupation. An appellate court determined that the trial court used an above-average work-life expectancy. Therefore, the plaintiff's award was reduced from $300,000.00 to $209,533.00 based on his ability to work as a security guard until the noted age of retirement (58.2 years of age), beginning at age 55.8. The plaintiff did not note how they arrived at the range for work-life expectancy but that the age of 55.8 was based on a table of statistical work-life expectancies prepared by other economists.

As vocational rehabilitation counselors, it is important to gather as much information relevant to work-life and be aware of the statistical data, even if outdated. The vocational expert alone may not be able to determine such information, and collaboration with an economist can be beneficial.

Guest User 5/21/22 Guest User 5/21/22

What Is A Life Care Plan? Breaking Down The Definition, Part 1

In testimony, life care planners are often asked, “what is a life care plan?” According to the International Academy of Life Care Planners, a 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 costs for individuals who have experienced catastrophic injury or have chronic health care needs.” Questions often arise regarding the different components of this definition. Life care planners are often asked, “what do you mean by dynamic?”

Dynamic refers to “continuously changing or developing.” Life care plans are considered dynamic or “needs-based,” and individuals’ needs are subject to change. Various circumstances may result in a modification to a life care plan, such as potential complications, new technology, a shift in medication regimen, or the continued need or removal of an item or service. What was once future medical treatment needs becomes past medical treatment when the patient has undergone or received some of the services previously outlined.

A life care planner should consider the risk for potential complications; however, specific complications the individual may experience may not be known on a more probable than not basis. Should an individual experience a complication directly resulting from the injuries identified in the life care plan, the life care plan would need to be amended to include the treatment related to those complications.

Technology is constantly evolving, and more efficient treatment options may become available in the future; however, it is challenging to determine or account for the future advancement of technology. This may necessitate a change in a life care plan over time.

Treatment options, in general, may change for the individual based on their needs at any given time. For example, the treating physician may recommend spinal injections for a certain number of years; however, the physician may determine that additional injections, procedures, or surgery may be needed at the end of that duration. A common change in future treatment involves the individual’s medication regimen. The types of medication may change as well as the dosage and frequencies as time progresses or as new medicines become available.

Respecting that the life care plan is a dynamic document, life care planners routinely reserve the right to amend plans based on updated information from physicians and the individual’s changing needs.

Guest User 4/23/22 Guest User 4/23/22

Tackling Life Expectancy in Life Care Planning

According to The International Association of Rehabilitation Professionals (IARP), life care planners evaluate individuals with disabilities or chronic health conditions to quantify the needs created by the disability or medical condition. The life care planner then develops an integrated plan that includes items and services required and the specific costs associated with these items and services.

According to the Life Care Planning and Case Management Handbook[1], “to accurately project lifetime daily, medical and rehabilitative care in a life care plan, an accurate prediction of life expectancy is needed.” However, there are no requirements in our standards of practice suggesting life care planners must calculate the actual costs through life expectancy. To calculate lifetime costs, a life expectancy and years of residual life must be selected to sum annual costs. Some life care planners independently provide a modified life expectancy based on the opinions of physicians or make assumptions using other resources. According to the IARP Code of Ethics, assuming invalid representations of fact, or altering the methodology or process without foundation or compelling reason, is unethical and could lead to inadequate funding for future resources.

When asked to comment on life expectancy, one option for life care planners is to use data from published reports such as the National Vital Statistics System. The Centers for Disease Control and Prevention (CDC) typically publishes this data annually. However, it is important to note that the most recent version (2022) is based on data collected from 2019 (each chart generally is two to three years behind due to data collection and research). These charts report life expectancy for the total United States population and life tables for males, females, and different races and ethnicities. Should a physician be unable to comment on the remaining years of life, life care planners can offer the option of using the least restrictive demographic category of male versus female from these charts as a courtesy to referral sources. Then the life care planner can provide the referral source with an estimate of lifetime costs before an economist adjusts the figures to present value.

Choosing a more specific life expectancy based on race, ethnicity, geography, co-morbidities, etc., requires the life care planner to make independent assumptions that could drastically impact the final lifetime costs. Therefore, we believe it is best to offer the least restrictive, binary male versus female life expectancies when this is requested. For example, what if an evaluee is of mixed race, has a history of heart disease, or is a smoker? These additional demographics and specific variables require assumptions that may not reach the more probable than not including criteria for life care planning. Furthermore, these assumptions may require medical opinions outside the scope of many life care planners.

[1] Weed, R. O., & Berens, D. E. (2019). Life Care Planning and Case Management Handbook (4th ed.). Abingdon, UK: Routledge Press.

Guest User 3/19/22 Guest User 3/19/22

Life Care Planning for Post-Traumatic Epilepsy

One common sequela of traumatic brain injury is the development of post-traumatic seizures or epilepsy. Post-traumatic seizures can result from secondary effects of head trauma, including cerebral edema, intracranial hemorrhage, cerebral contusion or laceration, alterations in the blood-brain barrier, or other neurochemical changes. The diagnosis and treatment of post-traumatic seizures represent specific challenges for life care planners to document reasonable future medical care.

In planning seizure treatment, the first challenge is confirming that the episodes experienced are actual seizures. The most common diagnostic test is an electroencephalogram (EEG). An EEG records brain activity during the time the test is taken. EEGs present a "snapshot" of brain functioning or epileptiform brain activity. The gold standard for diagnosing seizure disorder or epilepsy is to capture seizure activity on EEG that correlates to seizure-like behaviors. Infrequently occurring seizures may be challenging to capture on an EEG. When a precise diagnosis is elusive, physicians may order extended EEGs that last up to several days and videotape the patient to correlate brain activity with behavioral changes. Patients may have to be hospitalized to be observed as an inpatient in certain instances, especially if their medications are discontinued to increase the likelihood of catching seizure activity on EEG. Some nonepileptic events mimic seizures, including narcolepsy, Tourette's syndrome, convulsive syncope (body jerks after fainting), and pseudo seizures. Attention Deficit Disorder can also produce behavior mistaken for a seizure.

Once seizures are confirmed, the most common treatment is medication management, usually handled by a neurologist. Most neurologists work to titrate antiepileptic medications to a therapeutic level that reduces the occurrence of seizures while managing side effects. Classic side effects from anti-seizure medications can include dizziness, drowsiness, fatigue, aggression, irritability, depression, and loss of appetite. Occasionally, adjuvant medications such as antidepressants must be used to treat the seizure medication side effects. It is important for life care planning to include sufficient physician follow-up visits and laboratory testing to monitor medication levels and allow for trial and error with medications. Once seizures are controlled, patients can often have a good quality of life. However, seizure precautions may continue to be necessary, with activities such as driving, swimming, working around dangerous equipment, and working at heights.

About 30-40% of people who have epilepsy will develop what is known as intractable or refractory epilepsy, in which medications are not effective. The most common treatment for intractable epilepsy is a Vagal Nerve Stimulator (VNS) device. The Vagus nerve is responsible for regulating internal organ functions such as digestion, heart rate, respiratory rate, and certain reflexes like coughing, sneezing, and vomiting. A VNS is an implantable device designed to send electrical stimulation to the Vagus nerve as it travels to the brain. An incision is usually made near the left collarbone, and a thin device the size of a silver dollar is implanted. Electrical leads are run to the Vagus nerve, and the entire device and leads are sewn up under the skin. Periodic device replacement is necessary as the battery life diminishes and the technology is routinely upgraded. The life care planner should consider the costs associated with the implant and replacement of the stimulator (i.e., physician, facility, and technology fees) and include such in the life care plan.

Depending on the age of onset, treatment for trauma-induced seizures can be extensive and costly. Therefore, life care planners should consult with treating neurologists to discuss the ongoing needs of the evaluee and accurately fund for future care.

Guest User 2/12/22 Guest User 2/12/22

Actual, Expected, And Wage Earning Capacity

The typical assignment for vocational rehabilitation counselors in litigated personal injury cases includes the questions: “What was the plaintiff’s wage-earning capacity before the injury, and what is their wage-earning capacity after the injury?” Key to answering these questions are the concepts of actual earnings, expected earnings, and earning capacity.

Actual or demonstrated wages are historical earnings established through employment and compensation records such as social security earnings, tax returns, W-2 records, or pay stubs. In cases where there is an established work record, actual earnings can be a good measure of the pre-injury wage-earning capacity. Variables such as full-time versus part-time labor force participation and propensity to work are important in assessing whether actual or demonstrated wages are the most appropriate metrics for describing pre-injury earning capacity.

Expected earnings are estimated wages related to the plaintiff’s vocational profile. Expected earnings are determined based on the typical wages, usually given in a range, paid for occupations and jobs that a person could have worked in the past or can work in the future. For example, if a worker demonstrated the ability to earn $20 per hour in the past, we can expect they would have earned $20 per hour in the future but for an intervening incident. Expected earnings do not consider the worker’s efforts to maximize earnings by working the maximum number of hours at the highest-paid job they can perform.

Wage-earning capacity is the value an individual can expect to earn if they choose to work to their capacity. The estimates are based on the expected wages paid for particular occupations as determined through published statistical wage data and labor market research. However, wage-earning capacity is not always the maximum amount of wages related to an occupation in the labor market. Therefore, individual personal factors need to be brought into the assessment process.

The assessment of wage-earning capacity versus actual earnings should be used if there is not a well-established pattern of work suggestive of a history of working at capacity. For example, while finishing nursing school, an individual chooses to work in a nursing home as a Certified Nursing Assistant (CNA) and is subsequently injured. Their pre-injury earning capacity could be based on their demonstrated or actual wages as a CNA; however, it may be more appropriate to base the pre-injury earning capacity on the statistical wages for nurses.

The determination of pre and post-earning capacity is specific to the individual’s vocational profile, including age, education, training, work history, skills acquired and transferable skills, vocational test results, and physical and/or cognitive capacities. Therefore, vocational rehabilitation counselors need to consider the most appropriate method for communicating earnings in forming opinions regarding residual earning capacity.

Guest User 1/15/22 Guest User 1/15/22

Daubert Standard for Admissibility When Assessing Earning Capacity

When offering opinions regarding earning capacity, the vocational rehabilitation counselor’s testimony must be based on a reliable foundation. Specific requirements are outlined in the Daubert standards, which uphold that (a) a witness qualified as an expert by knowledge, skill, experience, training, or education may testify in the form of an opinion if the expert’s scientific, technical, or specialized knowledge helps the trier of fact understand the evidence; (b) the testimony is based on sufficient facts or data; (c) the testimony is the product of reliable principles and methods, and (d) the expert has reliably applied the principles and methods of the facts of the case. In addition, under Daubert, the expert’s opinion needs to be based on scientific evidence that has been subjected to peer-review and publication.

A widely accepted method to assess earning capacity is the RAPEL method, subjected to peer-review and publication. RAPEL stands for:

Rehabilitation Plan

The Rehabilitation plan is based on evaluating the injured party’s vocational profile, including age, education, training, vocational test scores, limitations, strengths, and functioning.

Access

Access refers to the transferability of skills and experiences from prior occupations to alternate occupations and jobs in the labor market.

Placeability

Placeability is the likelihood that an injured person would actually be placed into employment in an occupation. Placeability is affected by many factors, such as the economic situation of the geographic area and availability of open jobs in the relevant market, combined with the characteristics of the evaluee determined by vocational rehabilitation evaluation.

Earnings Capacity

Earnings capacity is the actual comparison of what an injured person could earn before and following the onset of impairment.

Labor Force Participation

Labor force participation references work-life expectancy, lost time in the labor market, and any effects of part-time versus full-time work.

When applying the RAPEL model, the vocational rehabilitation counselor can ensure compliance with the Daubert standard for admissibility when assessing earning capacity.

Guest User 11/20/21 Guest User 11/20/21

Flexibility in Life Care Planning

Life care planners practicing in a forensic setting face constant challenges that require flexibility in everyday practice. Life care planners are routinely challenged on their methodology, qualifications, expertise, and the foundation to develop their opinions. Life care planning is an ever-evolving field, and growth and change are inevitable.

To establish and maintain credibility in the field of life care planning, life care planners must stay abreast of court decisions that affect the work they perform and constantly re-evaluate their methodology to reflect changes over time. Adhering closely to the Standards of Practice for Life Care Planners provides guidance and clarity to ground our work. According to the Standards, a life care plan is a dynamic document, which reflects a process of change, growth, or activity.

What may have at one time been accepted as an appropriate methodology can change. For example, it is acceptable in many states to consult with treating physicians to obtain future medical recommendations that serve as the foundation of an individual's life care plan. However, California courts have decided it is considered hearsay in the recent past and cannot be used solely to develop the life care plan. According to the ruling, the treating physician's recommendations must be documented in medical records or sworn testimony (People v. Sanchez). As a result, the methodology the life care planner had long relied on must be somewhat modified to hold up in those court systems.

Another example of flexibility occurs when treating physicians change their recommendations for future medical care after the life care plan has been produced based on their recommendations. Whether in a deposition or medical record, the life care planner's responsibility is to amend their report to reflect the most current recommendations accurately. Routinely, life care plans will be updated and amended several times throughout the case, reflecting that it is a dynamic document.

Life care planners must be able to carefully balance following a set methodology while at the same time being open to changes in practice and being ready to explain those changes when questioned.

To schedule a complimentary consultation with one of our experts at Stokes & Associates, don't hesitate to get in touch with one of our Client Development contacts.

David Barrett
Cell 504-259-6557
dbarrett@stokes-associates.com

Kelly Bradley Ebelt (Texas)
Cell 713-205-2205
kebelt@stokes-associates.com

Stokes & Associates Experts:
Larry S. Stokes, Ph.D.
Aaron Wolfson, Ph.D.
Lacy Sapp, Ph.D.
Todd Capielano, M.Ed., LRC, CRC, LPC, CLCP
Ashley Lastrapes, Ph.D., CRC, CCM, CLCP, LPC, LRC
Brandy Bradley, MHS, CRC, LRC, CLCP
Elizabeth Peralta, M.Ed., LRC, CRC, CLCP

Visit Stokes-Associates.com

Refer a Case Assignment

New Orleans Office:
3501 N. Causeway Blvd. Suite 900
Metairie, LA 70002
Main: 504-454-5009
Fax: 504-455-1081

Houston Office:
1120 NASA Pkwy. Suite 220K
Houston, TX 77058
281-335-5300

David Barrett 10/23/21 David Barrett 10/23/21

Life Care Plan Physician Consultations and Medical Summary Letters

One of the key criteria for including items in a life care plan is a medical foundation. Items included in the life care plan must be more probably than not causally related to the indexed incident (ex. motor vehicle collision, on-the-job injury, etc.). Additionally, all items included must be deemed medically necessary, preventative, and rehabilitative.

One of the Standards of Practice for life care planners is to perform a comprehensive assessment including review of medical records, interview with the evaluee and family, and conferring with treating or consulting healthcare professionals. Occasionally, clearly stated treatment recommendations can be gleaned from a review of medical records or treating physicians’ deposition transcripts. However, the medical records often fail to specify the frequency and duration of specific treatment required. For example, a neurosurgeon may recommend a 2-level anterior cervical fusion in a medical report but not establish follow-up office visits, physical therapy, pre-surgery labs, diagnostics and imaging, post-surgery medication, or equipment/supplies. Life care planning is a collaborative effort amongst various professionals. An experienced life care planner can develop questions to present to treating and consultative health care providers to identify future needs.

It is not uncommon to consult with multiple medical providers in sub-specialty areas (ex. neurologist, spine specialist, pain management, etc.) on the same case to develop a comprehensive life care plan. After each conference, a summary letter is generated by the life care planner documenting the recommended treatment for future care and presented to the physician/health care professional for review. If any changes or additions are needed, this can be noted by the physician/health care professional so that the preciseness of recommendations is well documented. Only items that are considered more probably than not, based on a reasonable degree of medical certainty, are included in the life care plan.

The recommendations made by physicians and healthcare providers during conferences with the life care planner serve as a basis of items included in developing a life care plan. In addition, since a medical foundation is paramount in developing a life care plan, the following can further assist in life care plan development:

•   Physicians document in chart notes and reports recommendations for more probable future medical care needs of the patient
•   When taking the depositions of physicians, asking them to specify future treatment recommendations with projected time frames of procedures/surgeries and the frequency/duration of all treatment
•   Attorneys should also consider reviewing the life care plan with the physician(s) when taking their depositions to further confirm the proper translation of recommendations into life care plan items

To schedule a complimentary consultation with one of our experts at Stokes & Associates, please call one of our Client Development contacts.

David Barrett
Cell 504-259-6557
dbarrett@stokes-associates.com

Kelly Bradley Ebelt (Texas)
Cell 713-205-2205
kebelt@stokes-associates.com

Stokes & Associates Experts:
Larry S. Stokes, Ph.D.
Aaron Wolfson, Ph.D.
Lacy Sapp, Ph.D.
Todd Capielano, M.Ed., LRC, CRC, LPC, CLCP
Ashley Lastrapes, Ph.D., CRC, CCM, CLCP, LPC, LRC
Brandy Bradley, MHS, CRC, LRC, CLCP
Elizabeth Peralta, M.Ed., LRC, CRC, CLCP

Guest User 9/18/21 Guest User 9/18/21

Why Engage A Vocational Expert?

If you have ever wondered when to hire a vocational expert to assist in personal injury matters here are some issues to consider. Whether you are representing the plaintiff or defense, consider referring the claimant for an evaluation, if the injured individual:

is a younger adult,
has less than high school education, with little or no training or transferable skills,
has a limited work history in physically demanding jobs,
has physical, cognitive, or emotional limitations precluding return to their pre-injury occupation or occupations they held in the past

An analysis of the ability to work and earn wages can help to determine any difference in pre versus post-injury wage-earning capacity.

Our experts at Stokes & Associates frequently field questions regarding whether a case requires our assistance. Given the facts of the case, we may suggest an evaluation of the plaintiff to prepare for expert testimony, or to act as a non-testifying consultant to assist in clarifying lost wages, future medical costs, or other issues related to return to work.

An evaluation may not be necessary if the facts are obvious, but don’t miss an opportunity to present evidence if it can help you to advance your position in the case.

To schedule a complimentary consultation with one of our experts at Stokes & Associates, please call David Barrett at 504-454-5009 or email dbarrett@stokes-associates.com or visit www.stokes-associates.com.

Larry S. Stokes, Ph.D.
Aaron Wolfson, Ph.D.
Lacy Sapp, Ph.D.
Todd Capielano, M.Ed., LRC, CRC, LPC, CLCP
Ashley Lastrapes, Ph.D., CRC, CCM, CLCP, LPC, LRC
Brandy Bradley, MHS, CRC, LRC, CLCP
Elizabeth Peralta, M.Ed., LRC, CRC, CLCP

Visit Stokes-Associates.com

New Orleans Office:
3501 N. Causeway Blvd. Suite 900
Metairie, LA 70002

Houston Office:
1120 NASA Pkwy. Suite 220K
Houston, TX 77058
281-335-5300

Main: 504-454-5009
Direct: 504-608-6944
Cell: 504-259-6557

dbarrett@stokes-associates.com
www.stokes-associates.com

David Barrett 7/24/21 David Barrett 7/24/21

Why is the Claimant Interview Important in Vocational Rehab and Life Care Planning?

When conducting a life care plan or vocational assessment, the vocational/life care plan expert should have the opportunity to interview the claimant. An interview evaluation of the claimant provides the expert with current information from the claimant’s perspective. For example, a clinical interview covers topics such as Medical Summary (a chronology of medical history since the time of the injury), Current Medical Providers, Current Medications, Claimant’s Report of Pain and Physical Limitations, Independence in Activities of Daily Living, Equipment and Supply Needs, Prior and Subsequent Injuries and Residual Limitations, Heath Habits and Mental Health, Education and Work History, and Vocational Rehabilitation Goals/Plans.

An interview evaluation allows the vocational counselor/life care planner the opportunity to gather additional information regarding the claimant’s medical treatment not identified through a medical record review alone. For instance, during a clinical interview, the vocational counselor/life care planner often learns that the claimant began treatment with additional or new medical providers not identified through the record review. An interview may also determine that the claimant uses specific durable medical equipment and supplies that help improve their independence and provide pain relief. This equipment and supplies often are not known by the treating physician.

The interview evaluation also allows the vocational counselor/life care planner to collect detail regarding the educational attainment and work history. The vocational counselor/life care planner can then explore elements of the job because a job title alone may leave out important information like essential job duties. The interview also includes the tenure of employment in each position. Time in an occupation can assist the vocational counselor/life care planner to determine whether the claimant has met the specific vocational preparation required to gain the transferable skills for alternative work options. Job tenure can also predict the claimant’s wage-earning capacity, both pre-injury as well as post-injury. Vocational testing (available electronically) could also be administered during the evaluation when appropriate to inform rehabilitation potential and employability.

A clinical interview of the claimant allows for a thorough vocational and life care plan assessment. Obtaining detail through this interview process adds to the level of analysis needed for a thorough evaluation. Although we can perform a vocational or life care plan evaluation based on records alone, a meeting and interview with the claimant enhances the assessment process.

To strategize with one of our vocational rehabilitation or life care plan experts at Stokes & Associates, please call Dave Barrett at 504-454-5009, visit our website, www.stokes-associates.com, or e-mail dbarrett@stokes-associates.com.

David Barrett 6/26/21 David Barrett 6/26/21

Incorporating Telehealth into Modern Vocational Rehab and Life Care Planning (Part 2)

Be honest. Think back to January of 2020. Did you know what Zoom was? Maybe you had heard of Skype? Perhaps you had used Facetime? Since the Covid-19 pandemic, Zoom has officially become synonymous with videoconferencing, much like ‘Kleenex’ is used to signify something you sneeze into and ‘Googling’ is used to represent searching on the internet. At Stokes & Associates, we have been advocating the use of secure videoconferencing to conduct vocational assessments and life care plan evaluations since 2010. Since we last wrote about the issue in 2016, the worldwide pandemic has only accelerated the general public’s comfort with videoconferencing as an alternative to in-person meetings. From primary care visits to the in-home schooling of our children, videoconferencing has become ubiquitous.

Once the national state of emergency was declared in March of 2020, the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services issued guidance to make healthcare services easier. For example, these agencies eased HIPAA regulations, waived regulatory changes to ensure expanded reimbursement for services, altered licensing requirements to allow practitioners to provide services over state lines, and authorized providers to prescribe controlled substances via telehealth. In addition, professional organizations like the American Psychological Association (APA) also issued guidance regarding the use of online assessment that allowed psychologists and other behavioral health providers the opportunity to provide remote testing services.

Is telehealth here to stay? Results from a recent massive study of over 36 million adults published in the JAMA Network suggest significant increases in the use of telehealth that support its popularity. Data were analyzed from working-age individuals enrolled in private health plans from March 2019 to June 2020 and yielded impressive results:

Telehealth use increased from .3% of provider visits in 2019 to 23.6% in 2020.
In-person visits decreased by 37%
Behavioral health visits were virtual 46.1% of the time, while medical visits were 22.1%
Medical care costs decreased by 15% per enrollee from 2019 to 2020

The federal courts also followed suit when the Judicial Conference, the administrative policy-making body for the federal courts, found on March 29, 2020, under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), that “emergency conditions due to the national emergency declared by the President concerning COVID-19 will materially affect the functioning of the federal courts….to temporarily authorize the use of video or telephone conferencing…” This authorization spread throughout the federal and state systems, with U.S. Patent and Trademark Office accommodating video hearings, County registrars offering video marriage licenses, and Federal and State Supreme Courts hearing arguments via video conferencing. For detailed information regarding how specific state courts use technology to operate, check out the National Center for State Courts Data Visualizations.

We have appeared at in-person courtroom trials and continue to provide virtual testimony in many states. Although there are some ethical positions articulated by the vocational and life care planning credentialing bodies and professional organizations, development in technology seems to be moving faster than policymakers. Due to the nature of our professional methodology, we can collect vital information from some evaluees via videoconferencing when in-person interviews are not possible or preferred. By continuing to leverage video capabilities, we have been able to provide the full slate of vocational and life care planning services during the pandemic. We intend to encourage the continued use of remote evaluations to keep costs down and retain other efficiencies such as greater choice for evaluation scheduling options and online vocational testing.

To strategize with one of our vocational rehabilitation or life care plan experts at Stokes & Associates, please call Dave Barrett at 504-454-5009, visit our website, www.stokes-associates.com, or e-mail dbarrett@stokes-associates.com.

David Barrett 5/15/21 David Barrett 5/15/21

Loss of Wage Earning Capacity - Consultations with Physicians

Consultations with physicians to discuss the patient's functional ability can provide specific information to assist the rehabilitation counselor in determining potential vocational outcomes. We have developed a form to assist in estimating a person's workability and job accommodation needs. The following is an example of a physician consultation questionnaire used to gather such information. Feel free to use this tool when you are gathering information about a client.

Below is a summary of the questions included in the form. Click HERE for the form.

PHYSICIAN'S CONSULTATION FORM

Patient/Examinee Name:

1. What is the date of injury?
2. What was the date of the last examination
3. What is the diagnosis?
4. Have diagnostic tests been performed?

If so, please identify the tests, the date, and the findings?

5. What is the prognosis?
6. What is the current medical status?
7. Has the patient reached maximum medical improvement? Date?
8. If no, what is the expected date of maximum medical improvement?

9. Is the patient taking medication that impacts his/her ability to work?

Please explain any limitations:

10. Can the patient be released to his/her previous job or regular work?

11. Can the patient return to temporary light work duty? (Explain limitations or restrictions)

12. Can the patient work based on The Department of Labor Definitions of Physical Demands? Select the maximum strength demand.

___Sedentary _____Light _____Medium _____Heavy _____Very Heavy

13. Please give an opinion of work restrictions or complete a physical capacity work restriction form. If you do not have a work restriction or physical capacities form, one can be provided to you.
14. If the patient/examinee is not capable of working in any capacity at this time, when do you anticipate releasing them for work?

15. Are breaks required during the workday? Frequency? Duration?
16. Can the patient operate a motor vehicle?

Guest User 4/24/21 Guest User 4/24/21

Life Care Planning and the Medical Fees Directory

Life care planners need to obtain appropriate cost information for the recommended treatment in a life care plan while adhering to life care planning tenets and standards. The most common method is to conduct a survey of the recommended treatment and ask for the "billed price" or the cash pay price without discounts. A range of sources is then included in the life care plan. At Stokes & Associates, we present the results of cost research to ensure that the treatment or service is not being under- or over-funded.

Some consultants have begun using the Medical Fees Directory published by the Practice Management Information Corporation (PMIC) to obtain the cost information for medical services. The purpose of the PMIC is for physicians and providers to compare how their fees rank on a national basis. The text also reports the information can be utilized for negotiation with payers and other purposes. The PCIM did not intend this data for pricing life care plans.

Furthermore, the PMIC provides costs at the 50th, 75th, and 90th percentiles, based on national averages, and are generally reflective of payor allowables. The prices in a life care plan should reflect actual costs within the injured persons' geographic area, not national averages. The use of the 50th, 75th, and 90th percentiles by the PMIC omits the top 10% and the bottom 50% of cost information. A limitation of the resource is that by leaving out the bottom 50% and top 10%, the costs range may not include the treating physician's price or the Usual and Customary Rate (UCR) costs in the patient's geographic area.

The PMIC provides "GAF – Geographic Adjustment Factor," used to adjust the UCR by geographic area. For some areas, such as Mississippi, the text provides only one GAF multiplier for the entire state. It is unclear how specific this calculation can be to an individual's geographic area, given that the PMIC only provides one GAF in the whole state. While it is uncertain how reliable the GAFs are if a life care planner utilizes the PMIC, the GAF should be calculated because the costs across geographic regions can vary greatly.

The PMIC cost information is provided per CPT code. Unless the provider gives a specific CPT code(s) of services or the life care planner is exceptionally well-versed in how CPT codes are utilized, errors can quickly occur. This is especially true if the life care planner is researching the cost of surgery, which could have multiple CPT codes, which can also vary by provider. The use of CPT codes could also leave the life care planner vulnerable to being accused of exceeding their scope of practice. For example, a physical therapy evaluation could be one of three CPT codes, each representing a differing level of complexity. Within the description, the level of complexity is determined in part by using a "standardized patient assessment instrument and/or measurable assessment of functional outcome." In choosing one CPT code over another, it could be argued that the life care planner is deciding what should be determined by a physical therapist.

At Stokes & Associates, we take great care to ensure that we are using best practices. For that reason, we advocate against relying entirely on published fee schedules for life care planning, such as the PMIC. Using the PMIC, in our opinion, does not give a comprehensive cost analysis and distorts the information presented to the trier of fact, rending the information invalid and unreliable.

To find out more about our methods or discuss a potential case assignment, we offer complimentary consultations concerning "hypothetical matters."

To strategize with one of our vocational experts or life care plan experts at Stokes & Associates, please call David Barrett at 504-454-5009, visit our website, www.stokes-associates.com or email dbarrett@stokes-associates.com.

Larry S. Stokes, Ph.D.
Aaron Wolfson, Ph.D.
Lacy Sapp, Ph.D.
Todd Capielano, M.Ed., LRC, CRC, LPC, CLC
Ashley Lastrapes, Ph.D., CRC, CCM, CLCP, LPC, LRC
Brandy Bradley, MHS, CRC, LRC, CLCP
Elizabeth Peralta, M.Ed., LRC, CRC, CLCP

Visit Stokes-Associates.com

David Barrett 3/20/21 David Barrett 3/20/21

Organ Transplant Life Care Plans

When developing life care plans involving organ transplants, the life care planner is tasked with capturing the costs of complex medical care needs with immediate and lifelong implications.

When obtaining recommendations for future care needs, life care planners typically consult with treating or consulting physicians. This consultation can be difficult to arrange when an organ transplant is involved, as the treating physician may not comment on post-transplant needs. For example, regarding a lung transplant, a pulmonologist would refer the patient for an evaluation by a transplant team to qualify for a transplant. The treating pulmonologist makes the initial referral but is typically unable to comment on post-transplant care needs such as immunosuppressants. While a transplant physician can comment on post-transplant needs, the patient may or may not have been referred and evaluated at the time of the life care plan. Additionally, it can be challenging to schedule consultations with transplant physicians, usually due to extensive hospital group affiliations and a lack of experience and knowledge of the litigation system. In these cases, it may be prudent to engage a consulting physician who can comment on future care needs.

The life care planner also needs to be knowledgeable about the transplant procedure and its implications. Following a transplant, the patient may be at greater risk for infections, cancer, and other complications, which means the life care planner must ask about services related to the monitoring of these complications. Are increased primary care or dental visits required? Are dermatology visits warranted, given the increased risk for skin cancer? Would an annual flu shot be justified given the patient's compromised immune system?

Another consideration is the location of the patient to the nearest transplant center. For example, Patient A and Patient B both need a bilateral lung transplant. Patient A lives in Dallas, Texas, within driving distance to three transplant facilities. Patient B lives in rural West Virginia and will need to fly to receive treatment. Depending on the organ, transplant patients typically need to be near the transplant facility for up to three months postoperatively, followed by annual, multiple-day assessments at the transplant facility. The life care planner must consider costs for flights and extended stay lodging for Patient B to receive treatment. Other considerations for Patient B may include childcare and home and lawn maintenance while away receiving treatment. While Patient A and Patient B require the same surgical procedure, the life care plans will look drastically different when considering location differences.

Life Care Planning for transplant cases is complicated and requires a great deal of planning and forethought in case management. Transplant consultations often involve multiple bodily systems with variable future potential complications. It takes a team of experts to fully develop a Life Care Plan for such patients, whether engaged by the plaintiff or defense.

To strategize with one of our vocational rehabilitation or life care plan experts at Stokes & Associates, please call Dave Barrett at 504-454-5009, visit our website, www.stokes-associates.com, or e-mail dbarrett@stokes-associates.com.

David Barrett 2/20/21 David Barrett 2/20/21

Language Choices in Life Care Planning

When developing life care plans by consulting with physicians and other professionals for future medical care needs, it is essential to consider words carefully to ensure that all parties communicate effectively and are "on the same page."

We use terms like "on a more probable than not basis," "more likely than not," and "more than a 50% chance of being required" when asking about future medical care needs. The Standards of Practice for Life Care Planners states that "the life care planner facilitates understanding of the life care planning process" and "provides information about the life care planning process to involved parties to elicit cooperative participation." The person we are consulting with must understand what we mean by these terms to obtain the appropriate information. It may seem clear to the life care planner what is meant by these terms; however, different professionals may interpret them differently, especially treaters with limited experience consulting with life care planners.

In a recent case, we consulted with an orthopedic surgeon, Dr. Smith, to obtain his recommendations for John Doe's future medical care due to a motor vehicle accident. When we spoke with the surgeon, we needed to clearly communicate that we were inquiring about any care required from the present through life expectancy and only future medical care specifically related to the indexed incident. The care needs to be probable and not just possible. Our review of Dr. Smith's medical records for Mr. Doe noted that Mr. Doe had a spinal fusion due to this incident two years prior. Therefore, we asked if Mr. Doe would require an adjacent level fusion in the future due to adjacent segment disease. Dr. Smith said it was a possibility (not included in a life care plan). We went on to ask if, in Mr. Doe's remaining life expectancy, there was more than a 50% chance that Mr. Doe will require an adjacent level fusion due to the indexed incident. Dr. Smith stated that patients typically require an adjacent level fusion within 17 years from their initial fusion date. Based on Mr. Doe's age of 47, he would require an additional surgical intervention on a more probable than not basis (included in a life care plan.) Dr. Smith also recommended associated pre-and post-operative care. If we had not explained further and communicated effectively, Mr. Doe's life care plan would have been underfunded.

It is essential to document the information obtained in consultation and use accurate language so there is no confusion about the life care plan's recommendations.

To strategize with one of our vocational rehabilitation or life care plan experts at Stokes & Associates, please call Dave Barrett at 504-454-5009, visit our website, www.stokes-associates.com, or e-mail dbarrett@stokes-associates.com.

Larry S. Stokes, Ph.D.
Aaron Wolfson, Ph.D.
Lacy Sapp, Ph.D.
Todd Capielano, M.Ed., LRC, CRC, LPC, CLC
Ashley Lastrapes, MHS, CRC, CCM, CLCP, LPC, LRC
Brandy Bradley, MHS, CRC, LRC, CLCP
Elizabeth Peralta, M.Ed., LRC, CRC, CLCP