LTC Claims Advisory Toolbox — Section 4 Plans of Care
Chronic Conditions
A. Chronic Condition Defined
A1. A chronic condition is an impairment that is expected to last greater than 6
months. Functional status is stable and progressive decline is not expected in the
next 6 months. Examples of diagnoses that fall into the category of Chronic
Conditions are cerebral vascular accidents or strokes, coronary artery disease,
chronic obstructive pulmonary disease, or spinal stenosis.
B1. First consideration is what recent event occurred that caused the insured to
develop functional impairment. Often insureds with a chronic condition will initiate a
claim due to an acute condition related to the underlying chronic disease. This acute
condition has placed them in a weakened state and may have caused some changes
in their ability to perform activities of daily living. Examples of this scenario are an
insured with coronary artery disease who is hospitalized with congestive heart
failure, or a diabetic who is hospitalized due to diabetic coma. These insureds
coming on claim would initially have an Acute POC in place to help them regain their
pre-morbid level of independent functioning. However there will be claims when the
insured will not be able to achieve their prior level of independence or the caregiver
can no longer provide the care the insured requires. For these claims the insurer
would look to transition the insured from an Acute POC to a Chronic POC with a long
term focus.
Another reason an insured with a Chronic Condition would come on claim is that co
morbid conditions combined with their chronic disease has brought them to a point of
were managing ADLs independently is a problem. The chronic disease is stable and
physical deterioration related to the disease is not anticipated in the next 6 months.
A third reason is the primary care giver is no longer willing or able to care for the
insured who has required assistance with activities of daily living prior to filing for
benefits.
B2. Consider establishing a Chronic POC after all avenues of improvement in
condition have been explored through referrals to physical and occupational therapy
or a short term stay in a rehabilitation or skilled nursing facility.
B3. Conditions that are not stable and are expected to decline in the next six months,
should have a Progressive Condition POC developed.
B4. Functional and ADL Status should be verified with PCP
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LTC Claims Advisory Toolbox — Section 4 Plans of Care
Chronic Conditions
C. Assessment
C1. If an Acute POC was in place initially, determine if the highest level of function
has been reached. If it is time to transition to a Chronic POC the transition should
begin by obtaining another On-Site Assessment (OSA) to establish the insured’s
current ADL status, as well as other key findings routinely obtained in the OSA.
C2. Review medical records from the treating physician(s), physical and occupational
therapist, and rehabilitation or skilled nursing facility as appropriate. These reviews
will provide valuable information in assessing insureds with chronic conditions and
provide insight into care plan needs.
D. Activities of Daily Living
D1. Identify what assistive devices and/or home modifications might increase the
ability of the insured and their primary caregiver to care for him/her. Providing the
insured with some means to participate actively in their self care will promote a
sense of well being and may result in requiring a reduction in service levels required
to meet their needs.
D2. Identify which ADLs insured needs help with and determine:
• What type of assistance is required (hands on, cueing, standby)?
• How often the assistance is needed and who will provide the assistance e.g.
formal or informal caregivers, family etc?
• Determine the reasonable amount of time required to complete tasks to meet
the insured’s ADL needs. Factor in primary caregiver’s availability to provide
ADL assistance throughout the day.
E. Instrumental Activities of Daily Living
E1. Identify which IADLs the insured needs help with and determine:
• Who routinely provided the IADL assistance if other then the insured and is
that person still providing assistance?
• How often is the assistance needed?
• What community resources are available to support the insured’s needs?
• Factor in primary caregiver’s availability to provide IADL assistance
throughout the day.
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LTC Claims Advisory Toolbox — Section 4 Plans of Care
Chronic Conditions
F. Establish and Implement POC
F1. Review needs and limitations:
• ADL - In planning for ADL needs the challenge is to assist with the
insured’s functional limitations while maintaining the greatest level of
independence possible. This can be done through such actions as
obtaining DME and providing training on its use or referrals to physical
and occupational therapy. Also important is in establishing a POC is
coordinating care needs and services provided by informal caregivers and
community services with formal care provided through the policy’s
benefits. And then there’s maximizing, when appropriate, Medicare
allowable benefits to augment incurred costs associated with providing
services noted in the POC.
• Cognitive – If cognition is a problem but does not trigger the LTC policy
benefit it is important to accommodate for the challenges this will bring in
order to maintain the highest level of function while maintaining safety
• IADLS- A cost effective plan is put in place to meet these needs through
use of community resources, family, and informal services such as
church, neighbors, etc.
• Environmental – Review current living arrangements, safety, obtaining
equipment or make modifications to the environment so that the insured
has the tools to maintain the highest level of independence.
• Psychosocial – Identify support systems, family, informal care, services
provided by external sources that have been available to the insured and
can be used to augment the Chronic POC.
F2. Implement a Plan of Care that allows the highest level of Independence:
• Maintain highest level of independence while meeting the functional ADL,
Cognitive, IADL, Environmental and Psychosocial needs.
• Maintain current functional status while maintaining safety.
• POC should address respite for informal caregivers.
• If DME is identified in OSA that would increase level of function address
obtaining and training on its use in the POC.
• Facilitate contact with community resources used to augment the POC.
G. Home Health Care Considerations
G1. A POC should be developed with the insured’s and family wishes known.
Usually the goal is to stay home as long as able.
• POC should address all needs and services that are required to keep
insured at home.
• Carrier should communicate POC with MD.
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LTC Claims Advisory Toolbox — Section 4 Plans of Care
Chronic Conditions
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Duration and frequency of services should be identified on POC.
Due to the importance of maintaining stability of a chronic condition follow
up should be as follows:
• If POC is developed following an Acute POC follow up every 90
days until POC is in a maintenance mode then every 6-12 months.
• If this is a new claim follow up every 30 days for 90 days then
follow up every 90 days until POC is in a maintenance mode then
every 6-12 months.
Follow up on POC should include review of services provided and if they
continue to be appropriate given current needs/limitations.
• Verify needs and limitations with HHC benefits through review of
ADL notes, any clinical records related to recent care received,
and PT/OT records
H. Facility Considerations
H1. Is facility equipped to meet the needs of the Insured?
• Review facility records and verify the facility provides the services insured
needs and that policy is triggered.
• ALF services would be outlined in assessment, service plans and/or plan
of care.
• Skilled nursing facility assessment and POC are outlined in the medical
data set (MDS) utilized by Medicare certified facilities or, if not certified by
the facility’s care planning as found in the facility’s medical record.
• Follow up with the facility could be in 90 days, then in six months and
then annually to verify needs are met.
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