Life Care Planning; Health and Strength Maintenance

In earlier posts on my blog, I reviewed some of the important areas of consideration for a life care plan, including wheelchair needs, orthotics/prosthetics, and projected evaluations.  In my opinion, the area of health and strength maintenance as included in the plan is potentially one of the most important and beneficial considerations  for the client.

Part of the client assessment for a life care plan should include a review of the leisure and recreation activities that they enjoyed and participated in before onset of illness or injury.  The life care planner may find that adaptive equipment, specialty wheelchairs, and other items are a legitimate need for the client to pursue their leisure activities.  In turn, being able to take part in one’s chosen leisure activity can prove beneficial, both emotionally and physically.

In my physical therapy practice, I am particularly interested in my client’s ability to maintain the gains that they have made during their physical therapy treatment.  The same is true when developing a life care plan.  For example, consider a client who has a life care plan that allows for an annual physical therapy evaluation and treatment.  This is usually intended to address issues such as decline in function, update a home exercise program, or to evaluate for needed replacement of assistive devices.  The client may then have a need to maintain their strength and functional gains beyond what is provided by a simple home exercise program.  In this case, the life care plan may legitimately include an allowance for gym membership.

This is another example of how a physical therapist as life care planner brings a unique qualification to developing meaningful life care plans.  I invite you to contact me or visit the website for my company, NsTEP Life Care if you would like more information.

Total Shoulder Replacement: Looking Past the Surgical Site

In my physical therapy practice, I often treat patients that have had a total shoulder replacement (TSA).  I will routinely see these patients on the first post-op day.  The rehab orders from the surgical team typically indicate “begin pendulum exercises” for the involved shoulder, or “passive ROM only for the shoulder for __ weeks.”  In my opinion, a PT should look at other aspects of function and self-care, in addition to starting the patient on their home program.

When I approach the patient for the first time, I do a lot of observing.  There are a number of things I want to see, in addition to instructing them in their passive ROM exercises for the shoulder.  Can they roll over in bed, without assistance?  Can they come to sit at the edge of the bed?  Can they stand, walk, get to the toilet, etc?  I also want to know if they are going to have family assistance at home.  Often times, a family member will be able to help them if they are having problems with these key areas of mobility.  However, one must remember that most of the patients that have TSA are older, and their wife/husband may also have medical problems or functional deficits that will limit their ability to offer assistance.  Furthermore, the TSA patient may already have a preexisting functional deficit.  For example, they may need a walker for safe ambulation.  Following a TSA, they will not be able to use the walker for a period of time.

I am usually able to put together a picture of the TSA patient’s functional abilities and needs within 30 minutes or so.  If I am satisfied that they will be able to safely meet their basic skill needs at home, then all is well.   However, if the patient is demonstrating significant difficulty with mobility, to the point where I am concerned about their safety, I will contact the discharge case manager or the physician.   I express my findings succinctly, emphasizing the potential safety concerns.  I will indicate my recommendation that the patient be transferred to a skilled nursing facility, or possibly have home health care involved at the time of discharge home.

In summary, simply teaching the patient how to do their home exercise following TSA is only a small part of the initial PT assessment.  If you get the clinical impression that the patient will not be safe at home, speak up!

Mom and Dad’s Life Care Plan

Over my years in the physical therapy profession, I have developed a love of treating the older person.  This was not really by design on my part.  It is just something that fell into place as I matured as a physical therapist.  As a young PT assistant in the ’80s, I actually thought that I would be a famous PT treating elite athletes.  But, time has a way of placing one in their proper place if they are willing to go along.  I guess that is what happened to me.

I now find myself seeking to serve the older population as I build my life care planning business.  I believe that a life care plan can be a great benefit to the older person who has had a serious injury or illness.  Over the years, I have treated countless older people who have had a stroke, TBI, or some other illness.  Many times I have looked into the worried, stunned faces of family members.  Their concerns often go unspoken, but their faces say everything.  Is Dad going to live?  How will Mom be able to care for him?  Can we still stay at home, or will we have to move?  I don’t think I can afford to quit work and care for mom.

In cases like this, I believe that the life care plan can serve three important purposes:

• It can serve as a case management guide.  By interacting closely with the treatment team, I develop the life care plan to reasonably predict what the client’s future care needs will be.  This can take some of the guess-work out of planning for future care.
• The cost analysis for current and future care can help with predicting future expenditures that will be required.  For example, consider the older person who has a stroke, and recovers to the point that they can ambulate safely about the house.  Their life care plan may include considerations for structural alterations to improve accessibility in the event that the person becomes dependent on a wheelchair.
• The life care plan is a dynamic document.  As such, it can be revised in the event that the client’s situation or medical condition changes.

I encourage you to contact me if you are caring for an older person and are concerned about their future care needs.  My initial life care planning consultations are always complementary.

Home Safety for the Older Person; the Bathroom

Today I want to share more ideas on home safety for the older person.  These are some things that I look at when assessing their safety in the bathroom.  (This is not intended as an all-inclusive list, and it may vary depending on client-specific issues).

• Can they easily and safely access the restroom?  So many of the older homes have very narrow entry ways.  I recently performed an assessment for an elderly man who used a walker.  The entry to his bathroom was 22″ wide!  No way he could get in safely with his walker.
• Is there adequate space to turn in around?  Seems simple, but not really for the person using a walker or other device.
• If the clients bathes rather than showers, are they safe to get into and out of the tub?  Can they clear the step over into the tub (sometimes 14″ high)?  Often times, weakness of the legs and balance deficits will render this simple task impossible.  Sometimes a simple shower chair and a hand held shower hose will meet the need for bathing, without having to sit completely down in the tub.
• If there is a walk in shower, one still needs to assess the client’s ability to step into the shower and clear the threshold into the shower.
• Does the floor have a non-skid surface, or if there is a throw rug, does it have a non-skid back?  (Personal opinion: I recommend removal of throw rugs if there is even a hint of fall risk…)
• Can the person easily access the toilet, and can they easily and safely get up from the toilet?  An inexpensive toilet seat extender with arm rests can make a world of difference.
• Is the light switch easily accessible?  This is especially important for the older person who uses  walker, as they need to be able to turn the light on without removing both hands from the walker.  Also, there needs to be adequate night light in the bathroom.
• As with other areas of the home, the issue of clutter removal must be addressed in the bathroom.

In my opinion, any home safety assessment should include a gait and balance assessment of the client.  Severe balance problems that have not been addressed will probably lead to falls, even if the home is otherwise “safe”.  A word to all life care planners or others who hire a PT to do a home safety evaluation- ask them if they are going to include a balance and gait assessment as well.

Celebrate!

One of my older clients in my physical therapy practice recently told me “As a young man, I never thought I would have so many ailments as I got older.”  He shared with me how, as a young man, every day was worth living.  Every day was a new adventure for him. He lamented now over his inability to do simple things, like walk from his bed to the toilet, or sit up without feeling dizzy.

I have heard this or similar stories many times over the past 20 plus years.  But for some reason, this man and his genuine yearning for something good had an impact on me.  Maybe it was because he was so eloquent at contrasting his life as a young man and an older man, and he did it in only a few sentences.  Whatever the reason, this man taught me a lesson- I have chosen to pursue a profession that involves some level of compassion on a daily basis.  I must use that compassion to celebrate the simple things, not only in my life, but in the lives of those that I serve each day in my work.

May God bless you all, and remember- celebrate the little things!

Life Care Planning; Orthotics and Prosthetics

Previously on The Life Care Planner, I have discussed various components of the life care plan, including wheelchairs, attendant care, and projected evaluations.  Today, I will review orthotics and prosthetics for those suffering from various injuries.

According to the Amputee Coalition of America, vascular disease accounts for 82% of amputations.  Of those, 97% are lower extremity amputations.  The risk of vascular-associated amputation is greatest among males, and those who are African-American.

For the client who has had an amputation, the life care plan will include projected replacement schedule and maintenance needs for an appropriate prosthesis.  The life care planner will likely need to consult with a prosthetist to obtain information on replacement schedule and associated cost of the prosthesis.  The prosthesis is typically an expensive purchase.  For this reason, it is important to obtain more than one cost estimate for the prosthesis (if possible), and to obtain the cost estimates from providers in the client’s geographical area.

Assessing the client with amputation is an important part of the life care plan.  Simply including cost of future prosthetic needs may not ensure a good medical outcome for the client.  The life care planner will usually need to evaluate the client’s ability to perform such tasks as skin inspection of the residual limb, self dressing and other self care skills, and applying/removing the prosthesis itself.  Deficits in these areas will need to be addressed within the life care plan.  Of coarse, the life care planner may not have access to the client and may not be able to perform such an assessment.  This may be the case when the life care planner is working for the defense by reviewing a life care plan developed by plaintiff’s expert.

Orthotic devices (sometimes referred to as “orthotics”) will sometimes be an integral part of the life care plan for the client.  Examples of orthotics include ankle-foot orthosis (AFO), various splints to aide hand function, and extra depth shoes.  Consider the client who has sustained a severe orthopedic injury involving the leg.  He may be left with nerve injury that leads to foot drop.  An AFO may be prescribed to provide proper positioning of the foot and to prevent tripping during walking.  This client may then need extra depth shoes to accommodate the AFO.  As with a prosthetic device, the life care planner will need to provide for a replacement schedule and associated cost for the orthotic device.

As a physical therapist, I often evaluate patients with amputations and those who need various braces and other orthotics.  I can bring this ability to the life care plans that I develop for the client that may have a need for these devices.  Please contact me if you have more questions.

Home Safety for the Older Person, Part II

Here are more considerations when assessing the safety of a home environment for an elderly loved one.

• Do carpets in rooms lie flat, or are they wrinkled?  Wrinkled, torn carpets will cause trips and falls.
• If there are throw rugs in the home, do they slide or roll up when you push them with your foot?  As mentioned in a previous post, throw rugs are a potential trip hazard in the home of the older person, especially if they are already at risk for falls.  My personal opinion is that throw rugs should be removed from the home if the older person is at high risk for falls.
• In the kitchen, are the stove controls easy to access and easy to see?  Preferably, the controls should be on the front part of the stove, or to one side.  Are regularly used items easily accessible, or do you have to climb to reach items in high shelves?
• Are there portable heaters in the house?  If so,  the area surrounding the heater should be free of clutter.  Curtains should be at least 12 inches away from the heater.

I will focus on safety in the bathroom in a future post.

Shoulder Pain and Spinal Cord Injury

A life care planner is often called upon to write a plan for someone who has sustained a spinal cord injury (SCI).  In these cases, the life care planner may need to consider the effects of aging on the SCI disability.  One of the common problems that occurs in the individual with SCI is shoulder pain.

In 1999, KA Curtis et al published a study on shoulder pain in wheelchair users with paraplegia and tetraplegia.  The authors reviewed the prevalence and intensity of shoulder pain during daily functional activities in this population.  In this study of 195 individuals, they found that 59% of those with tetraplegia and 42% of those with paraplegia reported current shoulder pain at the time of the study.  They recommended that efforts to monitor and prevent shoulder pain should continue after rehabilitation is complete.

Think about it for a moment; can you imagine yourself as a person with a spinal cord injury, totally dependent on the use of your arms for transferring from one place to another?  Now picture yourself having to have shoulder surgery to repair a torn rotator cuff.  You no longer are able to use that arm for transfers, probably for a long time.  At this point, you become dependent on others for this basic mobility skill.

When preparing a life care plan for an individual with SCI, I will address this possibility as a potential complication as the person ages.  (Of course, this depends on the individual for whom the life care plan is being prepared.  Life care plans are written based on client-specific needs, rather than disease-specific needs.)  I do this if for no other reason than to educate the client and their loved ones on protecting their shoulders.  This is a common practice of mine in my physical therapy clinic.  I educate the active SCI patient on the importance of protecting their shoulders.  I also talk to them about what the future may hold as they age with SCI.  For some clients, there may come a time some years down the road when they will need to consider use of power mobility.

Please contact me if you have further questions about this topic or life care planning in general.

Source: KA Curtis, GA Drysdale, et al. Shoulder pain in wheelchair users with tetraplegia and paraplegia. Arch Phys Med Rehabil 1999; 80: 453-457.

Home Safety for the Older Person

I routinely treat elderly patients in my work as a physical therapist.  I will often counsel the patient and their loved ones about being safe at home, especially if I feel they are at risk for falls or injury at home.  Likewise, home safety considerations should be included in the life care planning process for the elderly client.  Some items that one should be aware of in the home of the older person:

• “Busy” floor patterns can create or worsen depth perception problems for the older person.
• Lighting throughout the home is important, even during daytime hours. Areas of perpetual shadow should be addressed with even lighting. Of coarse, the interior of the home should have adequate night light that provides well lit paths to commonly accessed areas of the home (i.e., restroom, bedroom). Make sure that a flashlight is handy at night.
• The aged individual may have skin changes that put them at risk for injury. For example, one may need to consider reducing the temperature of the hot water heater to avoid burns to the older person with frail skin.
• Slips, trips, and falls- Ensure that electrical cords are removed from the high traffic areas of the home.  Keep the home free from clutter.  Consider removing throw rugs, especially if your older loved one uses a walker.

I will periodically post more helpful information about home safety for Mom and Dad as they navigate the golden years!

A Physical Therapist as Life Care Planner

If you have done any investigation into the field of life care planning, you are probably aware that the many life care planners are nurses.  There are others from different medical professions that transition into life care planning, including rehab counselors, physicians, psychiatrists, etc.  However, there are few physical therapists that are also life care planners.  I am a physical therapist (PT) and life care planner, and today I will explain how the life care plans that I develop are enhanced by my background as a PT.

Point One- Training. Physical therapy programs are intense, and entry into these programs is competitive.  The didactic component of professional training in physical therapy includes assessment and treatment techniques for patients with a wide variety of disabilities or impairments.  For example, some of the areas of focus in my PT training included:

• neurology- spinal cord injury, acquired brain injury, peripheral nerve injury, neuropathies, etc.
• orthopedics- spinal fractures, multiple orthopedic trauma, joint replacements, ligament reconstructions, etc.
• the generally debilitated elderly person

Point Two- Experience. I have more than 22 years of experience in the field of physical therapy.  The first seven years of my career were spent as a PT assistant.  As a Physical Therapist since 1994, I have developed a rich background in assessment and treatment of the adult patient.  I am well versed in performing functional assessments to determine deficits in a person’s self care ability, and in determining the need for further PT intervention.

My ability to thoroughly assess functional deficits are a key component in my life care plans.  Many times, this information must be gathered from medical records, or through separate consultation with a physical therapist.  With a good understanding of a person’s functional deficits, I can interact confidently with all of the client’s treating medical team to determine what their future needs are.  I have developed confidence in interacting with the medicial team over the years.

In summary, I am able to develop a life care plan that is thorough and meaningful in determining a client’s future needs.  My ability to determine functional deficits, and the possible effects of aging with a disability put me in an ideal position to be a go-to person for life care plan consulting.  In invite you to visit my website www.nsteplifecare.com for more information.