LTC Claims Advisory Toolbox — Section 5 Plans of Care
Terminal Illness
LTC INSURANCE COMPANY
PLAN OF CARE
Terminal Illness
Claimant Name: ______________
Family Contact: ___________________
Care Coordinator: _________________
Telephone Number: _____________
Telephone Number: _____________
Telephone Number: _____________
Initial POC Date:________
Revised POC Date:_______, ________, ________
Date
Identified Need
5/20/07
Insured recently
diagnosed with terminal
disease and is expected to
die within 6 months
Insured will die
with dignity.
5/20/07
Insured has unplanned
weight loss greater than 5
lbs in 1 month
5/20/07
Insured has persistent
nausea and vomiting
related to chemotherapy
LTC Claims Advisory Toolbox 2007
Objective
Intervention
Frequency
Follow
Up
%
Objective
Reached
Referral for MSW to
assist with the dying
process
Initial
referral for
1 hr then
weekly for
1hr x4
weeks and
prn
5/27/07
Medicare
Hospice
Insured will
remain at current
weight
Referral for Registered
Dietician
6/20/07
Medicare
Hospice
Insured will
verbalize
decreased
nausea and
Skilled Nurse for
medication
management
Initial
referral for
1 hr then
monthly for
1 hr x3
months
Weekly for
1 hr x 9
weeks
7/22/07
Medicare
hospice
Contact/Tel
#
Payment
Source
LTC Claims Advisory Toolbox — Section 5 Plans of Care
Terminal Illness
vomiting
5/20/07
Insured reports increasing
pain related to end stage
disease process
Insured will
verbalize
satisfactory pain
control
5/20/07
Stage 2 Decubitus Ulcer
noted on coccyx
5/20/07
Insured unable to prepare
meals by self do to fatigue
Further skin
breakdown will be
prevented
Insured will
maintain
adequate
nutrition
5/20/07
Insured unable to bathe or
dress independently
related to weakness
associated with end stage
disease
LTC Claims Advisory Toolbox 2007
Insured will
maintain proper
hygiene
Skilled Nurse for
medication
management
Weekly for
1 hr x9
weeks
Skilled nurse for wound 1hr daily
x7 days
Referral to local meals
on wheels
X1
Homemaker
1hr daily to
prepare
meals x 2
weeks
1hr per day
7 days per
week x 4
weeks
HHA
7/27/07
Medicare
5/27/07
Medicare
6/3/07
!00%
Private
pay
LTC
insurer
5/20/07
Medicare
And
LTC
insurer