LTC Claims Advisory Toolbox — Section 5 Plans of Care
Cognitive Impairment
A. Cognitive Impairment Defined
A1. Cognitive impairment is a deterioration or loss in intellectual capacity that places
a person in jeopardy of harming him / herself or others and would need substantial
supervision by another individual to protect from threats to health and safety.
Acute Cognitive Impairment is a result of a disease process, injury, or chemical
cause with the expectation of recovery
Chronic Cognitive Impairment is a result of a disease process, injury, or chemical
cause without expectation of recovery and may be progressive in nature.
B. General Objectives
B1. Maintain highest level of functioning and safety and prevent primary caregiver
burnout.
C. General Considerations
C1. Identify general information such as:
• Identify if Acute or Chronic cognitive impairment, i.e. Is improvement or
deterioration expected?
• Recommend retesting as needed when improvement or deterioration in
prognosis (see F Cognitive Status POC considerations below)
• Assess insured’s behavior (i.e.; wander risk, assaultive/abusive behaviorphysical or verbal, sundowner’s syndrome, etc.)
• Has there been cognitive / neuro-psych testing done?
o What were the results?
o When were they obtained?
• Consider any other co morbid conditions which may impact functional
status.
• Current living arrangements e.g. home or type of facility.
C2. Identify the following:
• Level of Orientation
• Safety issues identified as danger to self or others
• Date and Results of any Cognitive screening or Neuro/Psych Testing
o If cause of cognitive impairment is acute in nature and improvement is
expected, the POC should include scheduling a re-test of MMSE at
appropriate time interval so appropriate adjustments can be made to
POC or assessment for discharging from benefit period.
o If cause of cognitive impairment is chronic in nature, and prognosis is
for rapid decline, POC should include scheduling a re-test of MMSE at
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LTC Claims Advisory Toolbox — Section 5 Plans of Care
Cognitive Impairment
appropriate time interval so appropriate adjustments can be made to
POC.
C3. Medication safety should be considered as many cognitively impaired individuals
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.
D. Activities of Daily Living
D1. Identify if the insured is capable of performing any ADLs. If not then:
• Identify the ADLs insured needs help with (see OSA)
• What type of assistance does insured require (hands on, Cueing,
Standby)
• Who provides the ADL assistance
• How often is the assistance needed
• Is improvement expected?
E. Instrumental Activities of Daily Living
E1. Identify if the insured is capable of performing any IADLs. If not then:
• Identify the IADLs insured needs help with (see OSA)
• Who provides the IADL assistance
• How often is the assistance needed
• Is improvement expected?
• Is assistance needed with medication management? – medication
safety should be considered as many insureds have extensive
medication regimes, numerous ordering physicians and frequent
medication changes.
F. Environmental
F1. Refer to the OSA for specific documentation of information on:
• Is there an Informal support system in place?
• Identify family dynamics, psycho-social issues.
• Consider safety hazards in the home (see below place of care
considerations).
• Are paid services currently in place?
• Facilitate access to community services such as Local Alzheimer’s
Assoc. Chapter, Safe Return Program, community drop-in visitation
programs.
• What are the payment sources available for services required?
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LTC Claims Advisory Toolbox — Section 5 Plans of Care
Cognitive Impairment
G. Place of Care
G1. It would be important to consider the goals of the family, and insured if capable.
If there is a stay at home focus, the POC should include all services (paid and
unpaid) to ensure maintenance of the highest level of function, activity and safety.
The primary unpaid caregiver’s needs should also be considered. Information
including educational brochures, Safe Return information, websites and local support
groups should be provided, along with a plan to provide respite as needed.
Discussion regarding respite through the use of adult day care centers in
combination with in home services will prove beneficial for the caregiver.
G2. Discussion with family caring for insured at home should acknowledge that a
progression of illness may eventually lead to a facility placement. If a decision is
eventually made for placement, let them know you can assist with locating several
eligible facilities.
Provide educational information to assist with the decision of finding a facility to meet
their individual needs and preferences.
G3. Discussion of safety factors in the home should be addressed which may include
removing stove knobs, turning the temperature down on the hot water source,
securing medications and potential harmful chemicals if swallowed, checking the
refrigerator for spoiled food, door alarms, wandergards, and any safety concerns for
the overnight.
G4. Measures to maintain orientation to time may be placed in the home such as a
poster, chalk board etc which posts the Day, Date, and other information as needed.
G5. Consider information on the setting in which care is provided when developing
the POC:
• Care At Home
o Does insured live with / without family?
o What type of dwelling does the insured live in?
o Is the dwelling in an urban or rural setting?
o What is the availability of community services- both covered and
uncovered?
• Facility Based Care
o Does the facility have a designated?
o If in a nursing Facility what level of facility e.g. skilled, intermediate,
dementia unit, etc. is the insured residing in?
o If in an assisted living facility, is there a dementia unit and if yes is that
where the insured resides?
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