This article describes the collaborative relationship between the physiatrist and life care planner/case manager when preparing a life care plan for a person with an amputation. The complexities and interrelationship of physical, emotional, and pain issues require medical expertise and knowledge for the development of prognosis and relevant recommendations. The life care plan requires coordination between medical and rehabilitation professionals to address the impact of amputation and its associated impairment on all life roles.
Key points
- •
The life care planner/case manager relies on the medical community to determine the nature and extent of impairment after a person has had an amputation.
- •
The life care planner/case manager has specific training in the medical aspects of disability.
- •
Physical medicine and rehabilitation physicians, also known as physiatrists, provide appropriate medical foundation for recommendations within their scope of practice.
- •
Prosthetists also may provide medical foundation for recommendations within their scope of practice.
- •
The life care planner/case managers/physicians focus on the unique rehabilitation needs of the individual patient.
Introduction
The physiatrist who specializes in rehabilitation of amputees may have experience and expertise to inform the life care planning process. These areas may include the following assessments, therapies, and recommendations:
- 1.
Expectation and changes of function throughout the amputee’s life span
- 2.
Potential medical issues that are likely or possibly to be encountered over the lifetime as an amputee
- 3.
Most useful prosthetic prescription(s)
- 4.
Frequency of prosthetic replacement (may be in conjunction with the prosthetist)
- 5.
Necessary or useful adaptive equipment
- 6.
Work restrictions given the type(s) of amputation
- 7.
Date most likely that the amputee will achieve maximum medical improvement
- 8.
Types of therapies recommended over the life span, including but not limited to physical therapy, occupational therapy, psychological counseling, vocational rehabilitation, and case management
- 9.
Visits to both the physiatrist and other specialty physicians
- 10.
Life expectancy determination
- 11.
Level of assistance necessary throughout life span
- 12.
Expected emotional adaptation to amputation and the necessity of counseling services with frequency and longevity
- 13.
Pain issues, including potential treatments and prognosis for pain improvement
The life care planner/case manager is part of the multidisciplinary specialty practice of life care planning. The accepted definition of a life care plan and the standards of practice that are published by the International Academy of Life Care Planners (IALCP) are discussed elsewhere in this issue so are not repeated here.
The life care planner/case manager looks to the medical community to define the nature and extent of impairment. The life care planner/case manager does not diagnose or prescribe medical treatment, unless this individual is a physician qualified to do so. The life care planner/case manager has specific training in the medical aspects of disability. The life care planner/case manager has particular expertise in translating the medical implications and prognosis as determined by the physician for a specific patient into recommendations for independent living, employment, and other rehabilitation areas. Specific medical recommendations and many rehabilitation recommendations must come from the medical expert(s), whereas the life care planner/case manager provides recommendations within their specific area of training and knowledge of local resources available and, importantly, the cost of those services and items.
The physiatrist involved in life care plan preparation may also be familiar with local and national trends in prosthetic fitting and the costs of various prostheses. A prosthetist may also be asked to provide a quote for their own prosthetic costs in the life care plan; a physiatrist may be familiar with the costing of prostheses and what costs are locally and nationally.
The life care plan must focus on the needs of the individual patient; the patient and their needs are treated as a unique case study with an n of 1.
Frequently, when a life care plan is coordinated for a patient involved in litigation, courts mandate deadlines and rules of evidence. These deadlines may not be compatible with the patient’s having reached maximum medical improvement. In these circumstances, a prognosis from a qualified physician(s) is more critical than ever. However, the standards of practice must be adhered to regardless of any artificially imposed deadline to ensure that proper foundation and methodology are used when preparing the life care plan. The specialized knowledge brought to this collaborative process then ensures a reliable and valid plan, focused on the rehabilitative needs of the individual patient.
The plan resulting from the collaborative process uses both quantitative and qualitative approaches combined with clinical judgment or what is sometimes referred to as experience understood of both the physician and life care planner/case manager. The practitioner’s specialized knowledge, grounded in proper methodology within the standards of practice, leads to a realistic and appropriate plan for the patient. The approach is tailored to the needs of the individual and is never akin to a formulaic paint-by-numbers approach. There is no 1 format for the report required. The sample report in this article is for purpose of example only. It is the content, based on sound foundation and accepted methodology, which is important. The life care plan should be supportable, within a degree of reasonable medical probability, regardless whether it is being prepared for the plaintiff or defendant in a litigation case.
The life care plan addresses specific individual needs across several areas. The list shown here is typical, but it is not meant to be exhaustive or all-inclusive.
- •
Projected evaluations
- •
Projected treatment needs
- •
Projected therapeutic modalities
- •
Medications
- •
Diagnostics
- •
Prosthetic needs
- •
Drug and supply needs
- •
Orthopedic equipment needs
- •
Wheelchair and accessories
- •
Scooter and accessories
- •
Ergonomic equipment needs
- •
Aids for independent functioning
- •
Home modifications
- •
Home care and residential care
- •
Leisure, exercise, and recreational equipment
- •
Future medical and surgical care
- •
Future medical and surgical risks
Specific treatment needs and prognosis regarding functional outcomes are critical and must be obtained from the physiatrist or other consulting physician specialist(s), as appropriate. Collaboration with the life care planner/case manager regarding realistic and appropriate needs and their coordination is carried out to promote independence in the least restrictive environment with considerations for the patient’s safety and dignity.
It is important for the physiatrist involved in life care planning to remember that rehabilitation and function for the person with an amputation are a continuing process. Often, the first prosthesis is not the same prosthesis that will be most appropriate in a year or 2, because the patient’s stump likely has changed shaped and lost soft tissue bulk. Also, as the person becomes more adept at prosthetic use, differing components may become more appropriate for subsequent prosthetic restoration. As with stroke or spinal injury patients, what the amputee is able to do 6 months after the amputation is usually less than what the amputee can perform, with subsequent comprehensive rehabilitation, after the amputation. This improvement in function should be anticipated and accounted for in the scope of the life care plan.
Tables 1–19 detail the elements of a hypothetical life care plan that addresses the evaluation, treatment, and rehabilitative needs of an individual who has had a left-knee disarticulation amputation. The tables are provided for purposes of example and to promote education and awareness of the various elements of a life care plan (see Tables 1–19 ).
| Item | Purpose | Provider | Age/Initiated Age/Suspended | Replacement Rate | Base Cost a |
|---|---|---|---|---|---|
| Amputee clinic (rehabilitation medicine) | Ongoing evaluation, monitoring, and treatment of left-knee disarticulation amputation and sequelae. Address chronic pain issues, surgical recommendations, and future medical and rehabilitation referrals | Local provider | Current age to life expectancy | Average 1–2 visits per year | |
| Primary care physician evaluation, monitoring, and treatment | Provide preventive care services, screening, health maintenance, and care specifically related to the effects of left-knee disarticulation amputation. Provide treatment recommendations, as needed. Medication management | Local provider | Current age to life expectancy | Average every 6 mo (above and beyond routine needs) |
a Base cost should be nondiscounted/market rate prices from verifiable data with referenced sources that are geographically specific when appropriate and available, with more than 1 cost estimate, when appropriate. “Accurate and timely cost information and specificity of service allocations that can be easily used by the client and interested parties” should also be identified.
| Item | Purpose | Provider | Age/Initiated Age/Suspended | Replacement Rate | Base Cost a |
|---|---|---|---|---|---|
| Physical therapy evaluation, monitoring, and treatment | Provide therapy with focus on strengthening, stretching, range of motion, and mobility in left lower extremity and knee. Provide gait training as needed, assist with endurance/conditioning with prosthesis related to functional tasks and monitor overuse issues related to hips, knees, and back. Develop individualized structured exercise program | Local provider | Current age to life expectancy | Minimum 1 block of sessions every 5–10 y (10–15 sessions each block) | |
| Occupational therapy evaluation, monitoring, and treatment | Conduct in-home evaluation to provide equipment/modification recommendations, including bathroom safety as the patient/evaluee ages with disability | Local provider | Current age to life expectancy | 2 evaluations total Specific needs pending outcome of each evaluation | |
| Weight loss program/nutritional counseling | Ongoing evaluation and monitoring of weight in light of left through-the-knee amputation | Local provider | Current age over next 2 y | 5 visits | |
| Individual/family psychological evaluation, monitoring, and treatment | Ongoing evaluation, monitoring, and treatment for emotional adjustment issues related to severe injury and resulting impact on body image, family, familial relationships, and employability | Local provider | Current age to life expectancy | Average weekly sessions for 6–12 mo, then average 1–2 sessions per month for an additional 5 y, then average 12–15 sessions per year for 5 more years. As needed thereafter |
a Base cost should be nondiscounted/market rate prices from verifiable data with referenced sources that are geographically specific when appropriate and available, with more than 1 cost estimate, when appropriate. “Accurate and timely cost information and specificity of service allocations that can be easily used by the client and interested parties” should also be identified.
| Item (mg) | Purpose | Provider | Age/Initiated Age/Suspended | Replacement Rate | Base Cost a |
|---|---|---|---|---|---|
| Trazodone b (50) | Assist with sleep | Local pharmacy | Current age to life expectancy | Average monthly | |
| Cymbalta b (60) | Management of neuropathic pain | Local pharmacy | Current age to life expectancy | Average monthly | |
| Deplin b (15) | Management of depression | Local pharmacy | Current age to life expectancy | Average monthly |
a Base cost should be nondiscounted/market rate prices from verifiable data with referenced sources that are geographically specific when appropriate and available, with more than 1 cost estimate, when appropriate. “Accurate and timely cost information and specificity of service allocations that can be easily used by the client and interested parties” should also be identified.
b Reflects current use. Physician may choose to alter dosage or change medication over time.
| Item | Purpose | Provider | Age/Initiated Age/Suspended | Replacement Rate | Base Cost a |
|---|---|---|---|---|---|
| Radiograph left femur | Monitor amputation site | Local provider | Current age to life expectancy | Average every 5 y | |
| Radiograph left knee | Monitor amputation site | Local provider | Current age to life expectancy | Average every 5 y | |
| Radiograph right knee | Monitor right-knee issues related to overuse | Local provider | Current age to life expectancy | Average every 5 y | |
| Radiograph hips | Evaluate and monitor for arthritis related to injury | Local provider | Current age to life expectancy | Average every 15 y | |
| Radiograph spine | Evaluate and monitor for spine symptoms related to injury | Local provider | Current age to life expectancy | Average every 15 y |
a Base cost should be nondiscounted/market rate prices from verifiable data with referenced sources that are geographically specific when appropriate and available, with more than 1 cost estimate, when appropriate. “Accurate and timely cost information and specificity of service allocations that can be easily used by the client and interested parties” should also be identified.
| Item | Purpose | Provider | Age/Initiated Age/Suspended | Replacement Rate | Base Cost a , b |
|---|---|---|---|---|---|
| Knee disarticulation endoskeletal prosthesis base (L5311) | Promote ambulating activities | Local provider | Current age to life expectancy | Average every 4–5 y | $4958.67 each |
| Above-knee test socket (L5622) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 4–5 y | $471.69 each |
| Above-knee acrylic lamination (L5631) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 4–5 y | $495.39 each |
| Above-knee total contact (L5650) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 4–5 y | $647.05 each |
| Above-knee flexible inner socket/rigid frame (L5651) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 4–5 y | $1354.01 each |
| Suction suspension (L5652) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 4–5 y | $491.56 each |
| Above-knee alignable system (L5920) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 4–5 y | $598.22 each |
| Flex foot system (L5980) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 4–5 y | $4570.84 each |
| Ultralight material titanium/carbon (L5950) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 4–5 y | $1010.71 each |
| Socks (L8430) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 2 y | 12 at $25.84 each |
a Base cost should be nondiscounted/market rate prices from verifiable data with referenced sources that are geographically specific when appropriate and available, with more than 1 cost estimate, when appropriate. “Accurate and timely cost information and specificity of service allocations that can be easily used by the client and interested parties” should also be identified.
b Costs are noted for educational purposes and reflect 2012 charges for items.
| Item | Purpose | Provider | Age/Initiated Age/Suspended | Replacement Rate | Base Cost a |
|---|---|---|---|---|---|
| Single-axis swing and stance knee (L548) | Promote ambulating activities | Local provider | Current age to life expectancy | Average every 4–5 y | $3183.95 each |
| Stance flexion (L5845) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 4–5 y | $1983.89 each |
| Stance extension dampening (L5848) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 4–5 y | $1190.22 each |
| Microprocessor control (L5856) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 4–5 y | $26,570 each |
| High-activity knee frame (L5930) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 4–5 y | $3725.57 each |
| Lithium ion battery (L7368) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 4–5 y | $558.62 each |
a Base cost should be nondiscounted/market rate prices from verifiable data with referenced sources that are geographically specific when appropriate and available, with more than 1 cost estimate, when appropriate. “Accurate and timely cost information and specificity of service allocations that can be easily used by the client and interested parties” should also be identified.
| Item | Purpose | Provider | Age/Initiated Age/Suspended | Replacement Rate | Base Cost a , b |
|---|---|---|---|---|---|
| Replacement socket base (L5701) | Promote ambulating activities | Local provider | Current age to life expectancy | Average every 2–3 y | $5002.90 each |
| Test socket (L5622) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 2–3 y | $424.66 each |
| Acrylic socket (L5631) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 2–3 y | $495.39 each |
| Above-knee total contact (L5650) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 2–3 y | $647.05 each |
| Above-knee flexible inner socket (L5651) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 2–3 y | $1354.01 each |
| Suction suspension (L5652) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 2–3 y | $491.56 each |
| Ultralight material titanium/carbon (L5950) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 2–3 y | $1010.71 each |
| Socks (L8430) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 2 y | 12 at $25.84 each |
a Base cost should be nondiscounted/market rate prices from verifiable data with referenced sources that are geographically specific when appropriate and available, with more than 1 cost estimate, when appropriate. “Accurate and timely cost information and specificity of service allocations that can be easily used by the client and interested parties” should also be identified.
b Costs are noted for educational purposes and reflect 2012 charges for items.
| Item | Purpose | Provider | Age/Initiated Age/Suspended | Replacement Rate | Base Cost a , b |
|---|---|---|---|---|---|
| Knee disarticulation endoskeletal prosthesis base (L5311) | Shower safety, access to swimming pool, promote overall health, weight management, and maintain and improve strength and agility | Local provider | Current age to life expectancy | Average every 5–10 y | $4958.67 each |
| Above-knee test socket (L5622) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 5–10 y | $471.69 each |
| Above-knee total contact (L5650) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 5–10 y | $647.05 each |
| Above-knee alignable system (L5920) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 5–10 y | $598.22 each |
| Waterproof single-axis hydraulic knee (L546) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 5–10 y | $3590.71 each |
| Manual lock (L5925) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 5–10 y | $491.72 each |
| Waterproof foot (L5972) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 5–10 y | $442 each |
a Base cost should be nondiscounted/market rate prices from verifiable data with referenced sources that are geographically specific when appropriate and available, with more than 1 cost estimate, when appropriate. “Accurate and timely cost information and specificity of service allocations that can be easily used by the client and interested parties” should also be identified.
b Costs are noted for educational purposes and reflect 2012 charges for items.
| Item | Purpose | Provider | Age/Initiated Age/Suspended | Replacement Rate | Base Cost a |
|---|---|---|---|---|---|
| Gel liners (L5659) | Prosthetic componentry | Local provider | Current age to life expectancy | Average every 9–12 mo | 2 at $673.02 each |
| TES belt (L5695) | Prosthetic componentry | Local provider | Current age to life expectancy | Average annually | $183.87 each |
| Standard maintenance including foot shell replacement, adjustments, minor repairs | Maintenance to ensure proper operation and fit of prosthetic unit | Local provider | Current age to life expectancy | Average annually | $500 per year |
| C-leg microprocessor knee | Maintenance to ensure proper operation and fit of prosthetic unit | Local provider | Current age to life expectancy | Average annually | $1000–$1500 per year |
a Base cost should be nondiscounted/market rate prices from verifiable data with referenced sources that are geographically specific when appropriate and available, with more than 1 cost estimate, when appropriate. “Accurate and timely cost information and specificity of service allocations that can be easily used by the client and interested parties” should also be identified.
| Item | Purpose | Provider | Age/Initiated Age/Suspended | Replacement Rate | Base Cost a |
|---|---|---|---|---|---|
| Antifungal cream 12 g (0.42 oz) | Reduce the risk of infection at amputation site | Local provider | Current age to life expectancy | Average every 2–3 mo | |
| Adaptskin (Adaptlabs, Bainbridge Island, WA, USA) | Maintain skin integrity and minimize hypersensitivity | Local provider | Current age to life expectancy | Average every 6–8 mo |
a Base cost should be nondiscounted/market rate prices from verifiable data with referenced sources that are geographically specific when appropriate and available, with more than 1 cost estimate, when appropriate. “Accurate and timely cost information and specificity of service allocations that can be easily used by the client and interested parties” should also be identified.
| Item | Purpose | Provider | Age/Initiated Age/Suspended | Replacement Rate | Base Cost a |
|---|---|---|---|---|---|
| Bilateral crutches (currently using) | Assist in ambulation, particularly when not able to use prosthetic device | Local provider | Current age to life expectancy | Average every 5–7 y | |
| Front-wheeled walker (currently using) | Assist in ambulation, particularly when not able to use prosthetic device | Local provider | Current age to life expectancy | Average every 5–7 y |
a Base cost should be nondiscounted/market rate prices from verifiable data with referenced sources that are geographically specific when appropriate and available, with more than 1 cost estimate, when appropriate. “Accurate and timely cost information and specificity of service allocations that can be easily used by the client and interested parties” should also be identified.
| Item | Purpose | Provider | Age/Initiated Age/Suspended | Replacement Rate | Base Cost a |
|---|---|---|---|---|---|
| Quickie 2 ( SouthwestMedical.com , LLC, Phoenix, AZ, USA) ultralight manual wheelchair b with 8-degree back rest bend, adjustable height arms, semipneumatic casters 6 × 1.5, adjustable angle foot plates, rear antitippers, ascent cushion, left amputee support, crutch holder, heavy-duty package | Mobility at home and work when unable to wear prosthesis. Help manage fatigue and fall risks | Local provider | Current age to life expectancy | Average every 5–7 y | |
| Manual wheelchair maintenance | Maintenance of wheelchair | Local provider | Current age to life expectancy | Average annually |
a Base cost should be nondiscounted/market rate prices from verifiable data with referenced sources that are geographically specific when appropriate and available, with more than 1 cost estimate, when appropriate. “Accurate and timely cost information and specificity of service allocations that can be easily used by the client and interested parties” should also be identified.
| Item | Purpose | Provider | Age/Initiated Age/Suspended | Replacement Rate | Base Cost a |
|---|---|---|---|---|---|
| Power scooter | For long-distance mobility, when unable to wear prosthetic device, fatigued, or when terrain difficulties exist | Local provider | Age 50 y to life expectancy | Average every 8–10 y | |
| Batteries for power scooter (needs 2) | Power for scooter | Local provider | Age 50 y to life expectancy | Average every 2 y | |
| Power scooter maintenance | Maintenance of power scooter | Local provider | Age 50 y to life expectancy | Average annually (1–2 h) | |
| Harmar lift (Harmar, Sarasota, FL, USA) for power scooter | Facilitate transportation of power scooter | Local provider | Age 50 y to life expectancy | Average every 10 y | |
| Maintenance for lift | Maintain safe operation of equipment | Local provider | Age 50 y to life expectancy | Average annually (1–2 h) |
a Base cost should be nondiscounted/market rate prices from verifiable data with referenced sources that are geographically specific when appropriate and available, with more than 1 cost estimate, when appropriate. “Accurate and timely cost information and specificity of service allocations that can be easily used by the client and interested parties” should also be identified.
| Item | Purpose | Provider | Age/Initiated Age/Suspended | Replacement Rate | Base Cost a |
|---|---|---|---|---|---|
| Ergonomic equipment and work station evaluation | Assist with work/educational efforts by assessing for specific equipment needs; specific needs pending outcome of evaluation | Local provider | Current age to life expectancy | Minimum 1 time | |
| Ergonomic equipment and work station needs | Specific equipment/work station needs pending outcome of evaluation | Local provider | Current age to life expectancy | Pending outcome of evaluation |
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
