LTC Claims Advisory Toolbox — Section 5 Plans of Care
Long Term Progressive
A. Long term-Progressive Condition Defined
A1. A long term progressive condition (LTP) is a progressively debilitating condition
leading to a steady and irreversible decline of functional ability- e.g. Parkinson’s, end
stage renal disease, etc. [Alzheimer’s and dementias are addressed under Cognitive
Impairment].
Impairment is expected to last greater than 6 months with often-unpredictable
progression of functional decline. No improvement in long term functional status is
expected.
These conditions can have physical as well as cognitive deficits. Examples are
cognitive impairment associated with Parkinson ’s disease or cardiovascular disease.
B. General Considerations
B1. General consideration in the development of the LTP POC
• Evaluate both immediate and long-term viability of informal support
system to supplement formal services. Family members, friends,
neighbors, etc provide informal care. LTPs will generally require
increasing hours of low intensity care as the disease progresses. As
such, long term care benefits should augment but not replace
functioning, established informal care. A well functioning/supportive
informal support system will most often be necessary in order to keep
the LTP in the community as long as possible. Address any service
coordination/coverage issues specific to informal care system.
Information can best be obtained through self- report at time of on-site
assessment.
• Claimants with functional impairment requiring 24/7
assistance/supervision due to safety/social concerns not covered by
LTC policy and not being implemented for any other reason can be
referred to the appropriate state social services dept.
• The POC should be developed when possible to optimize benefits
over the longest period of time when an insured has a limited lifetime
maximum benefit. Considerations are insured’s age, as in many
cases insureds with neurological conditions are younger than the
general LTC population, and prognosis as it relates to anticipated
progression of functional decline and the insured’s plan of benefits.
• In home assessment should address history of depression and
document if insured is exhibiting/reporting feelings of depression.
• POC should address the needs of caregivers as well as those of the
insured. This may include interventions such as exploring the potential
for respite care, support groups or reference to educational material
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LTC Claims Advisory Toolbox — Section 5 Plans of Care
Long Term Progressive
related to the specific condition. Services should be considered either
through the LTC benefit or through community resources.
C. Activities of Daily Living
C1. Since ADL functioning is a major component of the POC it will be important to
establish level of dependency in those ADL’s that are characteristically more
predictable/schedulable i.e. bathing, dressing from those that are considered, “care
on demand” i.e. transfer, toileting. The later will likely require some form of continual
access to a caregiver. While medical records are helpful an on-site evaluation will
provide a more accurate assessment.
Incorporate use of DME to replace human assistance when appropriate. Also
consider Occupational Therapy to increase potential for self-care and/or train the
primary caregiver on techniques to assist them in caring for the insured in the home.
These will both conserve benefit dollars as well as maintain an optimum level of
independence.
Address any service coordination/coverage issues among family members. The
POC should include care management interventions that address care-giving issues
that are raised by the family.
Services that are not related to the policy benefits should also be factored into the
POC as they are instrumental in helping the insured achieve the goals established in
the POC
D. Cognitive
D1. Although primarily physically based LTP conditions can also include cognitive
components e.g. Parkinson’s. If cognitive deficits are identified in medical records or
on-site assessment, the level of impairment must be factored into the POC.
E. Psycho-Social
E1. LTP illness can often include an associated depression as a result of decreasing
independence and the need for significant lifestyle changes. Assessment should
address history of depression and identify if insured is exhibiting/reporting feelings of
depression. When appropriate include recommendation of counseling on the POC.
If lack of socialization is a contributing factor to psycho-social problems consider
community recourses such as a local senior center, ADC etc. Information on such
services may be obtained through organizations such as the local area agency on
aging.
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LTC Claims Advisory Toolbox — Section 5 Plans of Care
Long Term Progressive
The POC should address the needs of caregivers as well as those of the insured.
This may include exploring interventions such as respite care, support groups,
counseling services etc. .
F. Instrumental Activities of Daily Living
F1. If appropriate and at request of claimant/family assist in the evaluation for
community based service alternatives such as MOW, ADC and community outreach
programs.
Medication safety should be considered as many LTPs have extensive medication
regimes, numerous ordering physicians and frequent medication changes. The
potential for polypharmacy always exists. It is most often best to work through the
primary caregiver to ensure that all physicians caring for the insured are aware of all
medications being taken by insured. However if the caregiver is unavailable or
unable to perform this task, the POC should address how this information will be
conveyed to those physicians caring for the insured.
G. Environmental Considerations
G1. Insureds with long term progressive diseases are increasingly susceptible to
falls as a result of generalized weakness and gait disturbances as their condition
progresses. The risk of falls can be reduced if the insured is functioning in a safe
barrier free environment. The POC should consider evaluation of the environment
when indicated as a concern during the on site assessment. The POC should
include follow up on implementing these recommendations that address safety
issues such as slippery floors, unsecured rugs, electrical cords, bathroom safety, as
well as procurement and use of equipment such as a tub bench, raised toilet seat,
safety rails, etc.
Occupational therapists are trained to perform such assessments and make
recommendations to address adverse findings. They can also evaluate the
appropriateness for home modifications such as ramps, expanding doorways etc. to
help the insured and their caregivers in managing day to day activities.
H. Place of Service
H1. Home Health Care
Include all services both covered/uncovered, paid/unpaid being received and
recommended.
H2. Facility Care
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LTC Claims Advisory Toolbox — Section 5 Plans of Care
Long Term Progressive
Assist the insured and their family in finding the most appropriate care setting
to meet their needs and provide guidance on conservation of benefits when
possible.
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