LTC Claims Advisory Toolbox — Section 5 Plans of Care
Terminally Ill
A. Terminally Ill Defined
A1. Insured’s who were independent with or without assistive devices in performing
their ADL’s prior to:
• Recent onset of or exacerbation of illness resulting in a life expectancy of 6
months or less.
• The illness will result in irreversible impairment, permanently disabling the
insured’s ability to regain functional independence.
B. POC Objective
B1. Maintain dignity throughout the dying process by supporting highest level of
functioning and safety for the insured and the family
C. General Considerations
C1. Gather the following information to assist in developing a POC from the on site
assessment (OSA):
• Is death imminent or is a period of deterioration expected over next 6
months?
• Results of Cognitive testing
• Current physical living arrangements
• Hospice involvement
C2. It would be important to consider the goals of the insured and his/her family. If
there is a stay at home focus, the POC should include all services being received to
ensure to maintain the highest level of function, activity and safety.
C3. The primary unpaid caregiver’s needs should also be considered. Information
including hospice, educational brochures, Safe Return information, websites and
local support groups should be provided, along with a plan to provide Inpatient
Respite in combination with in home services.
C4. Determine if the insured is receiving hospice services through Medicare and if
he/she is then coordinate the LTC benefits with the hospice coordinator to ensure
that the broadest coverage for all appropriate and needed services are available to
the insured in a coordinated manner.
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LTC Claims Advisory Toolbox — Section 5 Plans of Care
Terminally Ill
D. Environmental Factors
D1. The following factors are considered in developing the POC:
• Informal support system
• Family dynamics
• Paid and unpaid Services
• Availability and utilization of community services
• DME
E. Cognitive Functional Status
E1. The OSA will provide the following information which is important to factor into
the POC especially if cognition is identified as a problem.
• Level of Orientation
• Safety issues identified as danger to self or others
• Ability to appropriately administer prescribed medication
• Behavioral issues
• Level of ADL assistance needed related to cognitive impairment
• Level of IADL assistance needed related to cognitive impairment
F. Activities of Daily Living
F1. Assess the level of assistance required to safely perform ADL’s and whether
DME should be considered to assist the insured in performing daily activities to
minimize pain, and to maintain as much independence as possible through the
stages of their illness.
G. Psycho- Social
G1. Informal support systems including religious support groups, disease specific
support groups contacted by the insured or the family can be a comfort to the insured
and the family as they manage through this difficult period. These organizations
should be noted as a resource in the POC.
An understanding of the family dynamics and insured’s behavioral responses are
also important to consider in establishing realistic objectives in a POC.
H. IADL status
H1. Offer support to the insured by providing an appropriate level of IADL assistance
using formal and informal, homemaker services, chore services, transportation,
companion/sitter. Coordinate these services with the hospice agency if there is one
already working with the insured and his/her family.
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LTC Claims Advisory Toolbox — Section 5 Plans of Care
Terminally Ill
I. POC Monitoring
I1. If death is imminent weekly monitoring may be required to satisfactorily meet the
needs of the insured.
I2. If deterioration is expected over a period of several weeks monthly monitoring
may be adequate to keep the POC current and ensure the needs of the insured are
being met.
J. Home Health Care Information
J1. Include the following in the POC:
• Covered and uncovered services including support systems
• Type and frequency for all services and by whom
• Time frame of anticipated services
• Anticipation of increase or decrease in services
• Anticipation of additional services needed
• Payment source of services must include Medicare and Commercial products
J2. Have a discussion with family about the possibility that progression of the illness
may eventually lead to facility placement if unable to meet needs in a home
environment. If a decision is made for placement, assist the insured and/or family in
locating an appropriate facility if a hospice agency is not involved. When appropriate
provide educational information to assist with the decision of a particular type of
facility to meet their individual needs and preferences.
If a hospice agency is involved the LTC insurer should coordinate discussions on this
matter with them so that the insured and the family are not receiving conflicting
information.
K. Facility Care Information
K1. Levels of care settings may range from an assisted living facility to an inpatient
hospice facility. As always it is important to coordinate the POC with the hospice
agency involved in managing end of life care and providing emotional and spiritual
support to the family and insured so that LTC benefits compliment and do not conflict
with hospice services already in place.
K2. If the insured is at home and informs the insurer that they are moving into a
facility, offer to help facilitate and coordinate the transfer from home care to the
facility
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