LTC Claims Advisory Toolbox — Section 5 Plans of Care
Acute Conditions
A. Acute Condition Defined
A1. An Acute Condition is an acute or sudden episode related to an illness, injury,
surgical procedure or acute exacerbation of a chronic disease with an anticipated
recovery period of 90 days or less.
B. General Considerations
B1. Considerations in identifying and developing an Acute POC would be:
• Identify if primary diagnosis is related to an injury, sudden illness or
exacerbation of an ongoing medical condition. Diagnoses that could be
considered acute conditions include: fractures, joint replacements,
surgical interventions, motor vehicle accident, trauma, acute infectious
processes, gastrointestinal disorders, acute exacerbations of a chronic
disease process.
• Identify what the insured’s functional status was prior to event occurring
and the potential to return to prior level of functioning.
• Consult physician managing primary medical condition to ascertain
his/her medical plan of care for the insured and discuss type of LTC care
services identified by the insurer and the anticipated duration for such
services.
• Request Attending Physician Statement to confirm primary diagnosis and
determine if co-morbidities exist that have not previously been identified.
This form would typically request that physician identify, duration,
intensity and frequency of care required
C. Assessment
C1. Perform Telephonic Assessment to gather initial information pertaining to
procedures/ treatments that the insured has received as well as current treatment
modalities that are in place.
C2. Perform On Site Assessment to evaluate:
• Functional ability to perform ADL/IADL’s
• Cognitive status
• Current treatment modalities and compliance
• Use of adaptive equipment
• Environmental Factors
• Psychosocial and Support Systems
• Involvement of Community Resources
LTC Claims Advisory Toolbox 2007
1
LTC Claims Advisory Toolbox — Section 5 Plans of Care
Acute Conditions
D. Review of Assessment and Relevant Data
D1. ADL’s/IADL’s- Review current functional deficits and compare to insured’s prior
level of function. Identify agencies currently involved in providing care in the
insured’s home
D2. Cognitive – Review results of cognitive screening. If issues related to cognitive
impairment are identified, seek additional information to clarify if there was an issue
prior to this. This would entail conferring with family members or physician.
Evaluating the insured’s judgment and behavior will also provide insight regarding
his/her ability to manage medical condition.
D3. Determine if issues exist related to insured’s ability to follow through with current
treatment modalities and medication compliance. If the insured is not compliant with
administration of pain meds functional status will be compromised. If antibiotics are
not taken as prescribed, insured’s endurance will remain poor and the insured will
continue to remain in a weakened state. Medication compliance will assist in
promoting highest level of function.
D4. Environmental – Review current living arrangements. Is the insured able to
access and exit home safely? Review DME utilized. Verify that insured has been
instructed regarding the proper use of equipment. Determine if there is a need for
additional equipment increase safety and independence.
D5. Community Resources – Determine if utilization of community resources would
increase independence.
E. Establish and Implement POC
E1. Identify care needs and establish goals with insured regarding anticipated
duration of care and changes in intensity and frequency in POC to reflect changes in
condition while maintaining a safe environment.
E2. Establish type of services needed. Many services pertaining to an Acute
Condition may require skilled services such as PT, OT, or skilled nursing. If skilled
services are not in place and it is felt that the insured would benefit from this to
increase independence and safety in the home, the physician should be contacted to
discuss the benefits and request order.
E3. Telephonic follow up with insured for ongoing evaluation of care needs and
adjustments to POC as indicated. The frequency of calls for Acute Conditions is
generally on a monthly basis.
E4. Follow up phone calls to physician and therapists should be made for updates to
track progress.
LTC Claims Advisory Toolbox 2007
2
LTC Claims Advisory Toolbox — Section 5 Plans of Care
Acute Conditions
E5. Documentation from agencies should be reviewed to verify services being
provided and confirm POC is appropriate.
F. Monitoring the POC
F1. The management of an Acute Condition may involve a greater frequency of calls
because these conditions are short term and it is expected that the insured’s
condition will improve quickly. An initial Acute Condition POC may require that phone
calls are made as frequently as every 2-4 weeks depending on the insured’s medical
condition and progress with recovery. These calls should not be confused with
policy language that establishes time lines for eligibility determinations, as the
purpose of these calls is to determine if the POC is meeting the insured’s needs and
if any adjustments to the POC are required.
G. Home Health Considerations
G1. Establish payor source for all services that are being provided. Medicare vs.
LTC policy
G2. Identify available providers in area. Negotiate rates based upon reasonable and
customary charges for area. Follow up to ensure services are being provided as
indicated.
G3. Utilization of community resources should be considered when appropriate for
optimal level of independence and conservation of LTC benefits.
H. Facility Considerations
H1. At times, some insureds may require a brief stay in a facility prior to returning
home. In situations such as these it is important that the insured understands and is
aware of the plan for them to return to their own home.
H2. It is important for the family or insured to evaluate services offered by a facility
and verify that the facility will be able to meet the needs of the insured. Some
assisted living facilities can be considered as a possible alternative to skilled facilities
since many of them now market the ability to provide rehabilitative services to
improve functionality.
H3. Once a facility has been chosen, determine that the facility meets the
requirements as outlined in the policy. Obtain facility assessments and care notes to
LTC Claims Advisory Toolbox 2007
3
LTC Claims Advisory Toolbox — Section 5 Plans of Care
Acute Conditions
track progress. Ongoing communication should be made with the facility to discuss
insured’s progress and plan for discharge to home.
LTC Claims Advisory Toolbox 2007
4