By: Michael Fryar & Betsy Keesler
InQuis Global, LLC
Evidence-based life care plans and earning capacity assessments ostensibly may not appear to have similarities. However, close examination of their foundation requirements and overall tenets reveals both categorically have common and related developmental connections. This article will review these specific forensic work products with an end goal of identifying their developmental parallels and common denominators.
EVIDENCE-BASED LIFE CARE PLANS
A life care plan is formally defined within the published 2015 Standards of Practice (Third Edition) by the International Association of Rehabilitation Professionals (IARP) and the International Academy of Life Care Planners (IALCP) as follows:
“The life care plan is a dynamic document based upon published standards of practice, comprehensive assessment, data analysis, and research, which provides an organized, concise plan for current and future needs with associated costs for individuals who have experienced catastrophic injury or have chronic health care needs.”
- · LIFE CARE PLANNING STANDARDS & METHODOLOGY
An evidence-based and credible life care plan will be based upon adherence to published peer-reviewed life care planning standards of practice and empirically validated consensus statements. These guiding tenets inform the Life Care Planner of the methodological processes and the types of evidence/data necessary for their plans. The categorical types of evidence, data and guidelines utilized during the development of an evidence-based life care plan include:
- 1. Life Care Planning Standards of Practice
- 2. Life Care Planning Consensus and Majority Statements
- 3. Life Care Planning Assessment Information
- 4. Medical and Clinical Records for Evaluee
- 5. Testimony from the Evaluee
- 6. Direct Collaboration with Health Care Providers (Treating and/or Evaluating)
- 7. Testimony from Health Care Providers (Treating and/or Evaluating)
- 8. Clinical Practice Guidelines
- 9. Peer-Reviewed Journal Articles
- 10. Literature and Guidelines from Professional Academies, Societies and/or Organizations
- 11. Health Care Cost Databases
- 12. Medical Billing Records
Many actively practicing Life Care Planners maintain life care planning certification through the International Commission on Healthcare Certification (ICHCC). The ICHCC’s current practice standards and guidelines were released in 2021 and should be followed by all persons certified by the Commission. In addition to the ICHCC, three professional groups have developed standards for life care planning practice, to include the International Academy of Life Care Planners (IALCP), the American Association of Nurse Life Care Planners (AANLCP), and the American Academy of Physician Life Care Planners (AAPLCP). The standards from all three professional groups have been analyzed and the outcomes published within the Journal of Life Care Planning (Gamez, Johnson & Stajduhar, 2017). In summary, all three sets of published standards present the need for professional collaboration when developing a life care plan. Specifically, the noted 2017 peer-reviewed life care planning publication concluded the following:
“Based upon a review of data from each of the three documents, overlap is apparent. Specific reference to collaboration is seen throughout all three standards of practice, reinforcing the interdisciplinary nature of life care planning.”
- · LIFE CARE PLANNING CONSENSUS REQUIREMENTS
In addition to published standards, consensus and majority statements have been developed for the practice of life care planning. The most current version is found published within the Journal of Life Care Planning (Johnson, C; Pomeranz, J. & Stetten, N, 2018). The publication outlines that the findings reached are applicable to all Life Care Planners, regardless of their educational/occupational background and/or professional affiliation. Of note, 89 full consensus statements were published during 2018, secondary to the Delphi study, which evaluated decades of professional Summit information with the aid of Life Care Planners across multiple committees and rounds of formal analysis.
Echoing the themes of published standards, the consensus reached through the past Delphi study included collaboration with health care providers/professionals as an essential requirement for the development of a life care plan. Thus, such collaboration should be readily evident through clear documentation within an evidence-based life care plan. Specifically, published life care planning consensus includes the following foundational requirements for a life care plan:
“84. Review of evidence-based research, review of clinical practice guidelines, medical records, medical and multidisciplinary consultation and evaluation/assessment of evaluee/family are recognized as best practice sources that provide foundation in life care plans.”
- o Scope of Practice & Foundational Requirements
Life Care Planners emerge from a variety of health care and educational backgrounds, such as Nursing, Medicine, Allied-Health, Mental Health/Counseling, etc. Each of these professionals has a well-defined scope of practice, in which they must remain, when developing a life care plan. As such, rarely, if ever, is one person fully qualified to make all the recommendations for a comprehensive and evidence-based life care plan. Therefore, it is imperative that the Life Care Planner collaborate with appropriate and necessary treating and/or evaluating health care providers to obtain plan recommendations that are outside of their scope of practice. More precisely, published consensus outlines the following requirements for the Life Care Planner:
“81. Life care planners seek recommendations from other qualified professionals and/or relevant sources for inclusion of care items/services outside the individual life care planner’s scope(s) of practice.”
As a basic example, Registered Nurses (RNs) cannot prescribe medications. It would be outside of their professional scope to attempt such. Therefore, medication recommendations within the life care plan must have a foundation from a qualified health care provider who is able, by virtue of their scope of practice, to prescribe medications.
In addition to establishing foundation through health care collaboration, a Life Care Planner can document direct connections between an evaluee’s medical records and/or health care providers’ testimony to the future care and treatment recommendations of their plans. However, Life Care Planners should not attempt to fill in the informational gaps pertaining to the frequency and duration of future care and services when such matters are outside of their scope of professional practice(s) and were not clearly documented within the medical records or testimony reviewed.
Also, published life care planning consensus requires the Life Care Planner to include relevant evidence-based research and guidelines within their plan’s foundational framework. Such resources may include guidelines from medical academies, professional associations and/or governmental agencies, etc. as well as peer-reviewed journal publications. Based upon consensus, the overall research, resources and processes utilized during life care plan development must be reliable, consistent, transparent and credible.
The consensus statements require verifiable data from appropriately referenced resources be used during the development of a life care plan. The plan’s cost data, when reviewed through the same sources by another Life Care Planner, should be reproducible. Also, the costs identified in a plan should be geographically specific to the evaluee. Costs of medical care and treatment are not equivalent across the country, a state or even a larger region for that matter. Moreover, the life care planning community has adopted the use of Usual, Customary and Reasonable (UCR) costs, as defined by the American Medical Association (AMA), for the development of a life care plan. This matter is outlined within a field treatise, the Life Care Planning and Case Management Handbook (Fourth Edition, Weed & Berens, 2018). Due to the requirements inherent for the defining of UCR, more than one cost source will need to be utilized by Life Care Planners in their plans. The same requirement of multiple cost estimates is outlined within the published consensus statements. Per consensus, the cost data of a life care plan should reflect market rate pricing and not be discounted in any manner. Finally, as with all data and processes of the life care plan, the cost data utilized should be reliable, consistent, transparent and credible.
- o Individualized Life Expectancy
Published consensus requires that the life care plan be individualized to the evaluee. Such developmental requirements apply to all aspects of the plan to include the life expectancy projection. Most Life Care Planners are not life expectancy experts, and therefore must rely upon the expertise of other professionals for an individualized account of the evaluee’s expected longevity. The peer-reviewed life care planning literature outlines the complex methodological processes necessary to arrive at individualized conclusions of life expectancy for a life care plan, and strongly cautions against endorsing only general population findings. As consistent with the need for medical foundation when qualifying treatment requirements outside of one’s scope of practice, the Life Care Planner, that is not a life expectancy expert, should defer life expectancy determinations to a qualified expert. Otherwise, the Life Care Planner would be guilty of providing an opinion that violates accepted life care planning consensus and standards.
- · CASE SCENARIOS & REVIEW
Hypothetical case scenarios and subsequent reviews are offered below for illustrative and educational purposes regarding evidence-based life care plans:
- o Case Scenario #1 (Traumatic Brain Injury Secondary to a Fall)
A 28-year-old male evaluee suffered a Traumatic Brain Injury (TBI) after falling from a third story building under construction. The TBI resulted in multiple long-term issues including executive deficits, vision deficits, hearing deficits, depression and anxiety. Following the completion of inpatient rehabilitation care, the evaluee was discharged to his home within the community. A Registered Nurse (RN), who is also a Certified Life Care Planner (CLCP), completed a life care plan for the evaluee. The life care plan’s narrative included a summary of the medical treatments received thus far by the evaluee from the medical records. Also, the life care planning narrative outlined past diagnostic testing completed, a list of the evaluee’s current medications and dosing, and the identification of all records that had been analyzed by the Nurse. Her plan included outpatient medical services the evaluee was actively receiving: Physiatry, Neuro-Ophthalmology, Neurology, Audiology, and Psychology. Based upon her clinical knowledge, the RN, independently and without collaboration, determined all the future medical and psychological care, diagnostic testing, medications, future attendant care, and other support services needed by the evaluee, including their future frequency and duration. Such future care information was not found within any of the medical records reviewed and testimony from the health care providers had not been obtained before release of the life care plan.
- o Review of Case Scenario #1
Development of the life care plan did not include any type of documented collaboration with a treating or evaluating health provider for the evaluee. Also, there was not any direct link made between the medical records reviewed and the specific treatment/care recommendations as issued within the life care plan by the Nurse. Moreover, the Life Care Planner did not identify any clinical practice guidelines, empirical research or peer-reviewed literature as specific foundation for the content of her plan. Finally, the Life Care Planner did not have testimony from a treating or evaluating health care provider for foundation either. In summary, the RN acted well beyond her scope of practice when she independently opined about future care and treatment for the evaluee absent necessary medical foundation for the same. Ultimately, the life care plan lacked the required credible and reliable data, as well as the overall foundational information necessary to formulate an evidence-based plan that is consistent with published life care planning consensus and standards.
- o Case Scenario #2 (Traumatic Burns Secondary to a Motor-Vehicle Accident)
A 56-year-old female was involved in a motor vehicle accident (MVA). The car exploded before the evaluee could be evacuated by emergency personnel. As a result, the evaluee suffered second and third degree burns over 60% of her body. After receiving extensive acute care services, she was discharged home and began outpatient services, wherein she received care and treatment from a Physician Burn Specialist, Reconstructive Burn Surgeon, Physical Therapist, Occupational Therapist, and Psychologist. The evaluee’s subsequent life care plan was developed by a Certified Rehabilitation Counselor (CRC). The Life Care Planner completed an in-home assessment of the evaluee, and multiple consultations were accomplished by him with the outpatient medical and clinical treatment teams. The consultative recommendations received were carefully documented by the Life Care Planner and fully endorsed through signature by the treatment teams. Subsequently, these medical and clinical recommendations were included into the evaluee’s life care plan. The CRC independently made recommendations for future vocational rehabilitation services within the life care plan. Also, the CRC made direct reference to published clinical practice guidelines for burn care, and peer reviewed journals regarding the psychological supports necessary to aid with emotional adjustment following a severe burn. Also, additional pertinent details of current treatment, as found within the medical records, was noted within the life care plan. The life care plan included a comprehensive list of all medical, clinical and legal documents reviewed during development. Present-value calculations were deferred to an Economist and total calculations were not issued by the Life Care Planner within the plan. Finally, the Life Care Planner deferred the determination of an individualized life expectancy for the evaluee to a qualified expert.
- o Review of Case Scenario #2
This Life Care Planner included multiple areas of foundation needed for an evidence-based life care plan. Of important note, the CRC remained within his scope of practice and relied upon other qualified health care providers, published clinical guidelines, literature, and medical records to support the recommendations of the plan. The CRC appropriately deferred other related determinations to qualified experts (i.e., present-value calculations and life expectancy). Overall, the life care plan contained credible and reliable data as well as the foundational information necessary to formulate evidence-based conclusions that are consistent with published life care planning consensus and standards.
EVIDENCE-BASED EARNING CAPACITY ASSESSMENTS
- · EARNING CAPACITY METHODOLOGY & STANDARDS
Similar to the life care plan, the determination of an evaluee’s earning capacity before and after an injury and/or chronic health condition is a complex endeavor, requiring adherence to a peer-reviewed and accepted methodology, as well as professional standards. Typically, professionals completing these assessments have an educational and professional background in vocational rehabilitation. A properly developed earning capacity analysis should incorporate evaluee assessment information, standard classifications, relevant research data, statistical information and foundation from necessary medical and/or clinical professionals. The objective evidence, information and data gathered should inform the final clinical judgements reached regarding an individual’s overall capacity for employment and wages within the competitive labor market.
The Commission on Rehabilitation Counselor Certification (CRCC) is the governing national professional organization that manages the Certified Rehabilitation Counselor (CRC) credential as maintained by many of the vocational rehabilitation professionals completing earning capacity assessments for forensic purposes. Published CRCC forensic standards require the utilization of methodologies appropriate to the evaluation process performed. There are multiple published earning capacity methodologies within the peer-reviewed vocational rehabilitation literature. These published methodologies provide the structure and guidance necessary to arrive at objective and valid earning capacity conclusions. A Forensic Vocational Rehabilitation Consultant (FVRC) should be able to discuss the specifics of the published earning capacity methodology adhered to during the assessment process and fully describe the data/evidence utilized for final clinical judgements/opinions.
- · CONTENT ANALYSIS & OBJECTIVE DATA
Qualitative analysis of the content factors found within earning capacity assessment reports has been accomplished and the empirical findings were published within the peer-reviewed Rehabilitation Professional journal (Robinson, Young & Pomeranz, 2009). Specifically, the research determined 22 factors were included within at least 50% or more of the forensic vocational rehabilitation reports analyzed regarding employability and earning capacity.
The specific 22 content factors identified included:
- Employment-Past Work-Job Title (100% of the reports)
- Personal-Gender (100 % of the reports)
- Educational-Secondary (97% of the reports)
- Employment-Past Work-Employment Data (97% of the reports)
- Personal-Age (97% of the reports)
- Employment-Past Work-Job Duties (90% of the reports)
- Medical-Treatment History (90% of the reports)
- Purpose of Assignment (90% of the reports)
- Employment-Past Work-Employer Name (87% of the reports)
- Employment-Past Work-Pay Rate End (80% of the reports)
- Functional Limitations (70% of the reports)
- Medication-Prescription (67% of the reports)
- Transportation-Driver’s License (67% of the reports)
- Psychometric-Vocational Testing (67% of the reports)
- Familial-Martial Status (63% of the reports)
- Educational-Secondary-Date of Highest Grade (60% of the reports)
- Secondary Medical Conditions (60% of the reports)
- Educational-Secondary-Highest Grade (57% of the reports)
- Employment-Past Work-Physical Requirements (57% of the reports)
- Familial-Children (57% of the reports)
- Literature Resources-DOT (57% of the reports)
- Educational Factor-Vocational (53% of the reports)
The core 22 factors identified through empirical analysis should, at minimum, be considered by a FVRC during the course of analyzing an evaluee’s earning capacity and arriving at evidence-based conclusions. Also, during the course of earning capacity assessment, evidence-based practice requires the consultant to directly consider objective data. Specifically, published CRCC standards require the FVRC utilize objective data for the determination of unbiased evaluation conclusions (CRCC Code, Section F: Forensic Services). The sources of such data may vary, but often include information from governmental surveys, wage and employment databases, professional associations, non-profit organizations, trade associations, research centers, peer-reviewed literature, published professional/medical guidelines, industry literature, and United States Department of Labor (USDOL) publications, as well as the evaluee’s tax, employment and academic records, etc.
- · FUNCTIONAL, ENVIRONMENTAL & MENTAL CAPACITY DETERMINATIONS
Multiple published CRCC advisory opinions outline that it is outside the scope of professional practice for a Certified Rehabilitation Counselor (CRC) to determine any type of functional work capacity for an individual. Moreover, based upon vocational rehabilitation treatises, such decisions should be made by qualified and licensed physicians and/or mental health practitioners (Robinson, 2014 and Weed & Field, 2012). In contrast, the FVRC’s professional role includes evaluating and determining the individualized impact that medically and/or clinically established physical, mental and/or environmental guidelines will have upon an evaluee’s employability, placeability and overall earning capacity. In summary, it is professionally inappropriate for a FVRC to determine or assign a specific occupational strength level or other functional, environmental, cognitive or psychological work parameter to an evaluee in the absence of foundation established by a licensed physician or other qualified health care provider.
- · CLINICAL JUDGMENTS/OPINIONS & EARNING CAPACITY DETERMINATIONS
Ultimately, within the guiding context of a published methodology and professional standards, and based upon assessment findings, objective data, research analysis and the application of informed clinical judgement, the FVRC can, to a reasonable degree of probability, reach conclusions regarding an evaluee’s pre-injury and post-injury earning capacities. Specifically, published peer-reviewed literature within Rehabilitation Professional (Field, Choppa & Weed, 2009) outlines that clinical judgements/opinions should include relevant information/data, follow a widely accepted and peer-reviewed methodology, adhere to relevant standards of practice, utilize statistical studies and, when professionally necessary, include valid and reliable testing instruments. Finally, the authors outline that the judgements/opinions reached by the Rehabilitation Professional must be unbiased, ethical and professional in nature.
After appropriate clinical judgements/opinions are finalized and the overall earning capacity assessment report is completed, the information can be provided to a Forensic Economist (FE) for calculation(s) related to the determination of present value. A forensic vocational rehabilitation treatise (Robinson, 2014) describes the following, relative to the professional hand-off between the Vocational Rehabilitation Expert (VE) and the Forensic Economist (FE):
“As will be seen, the typical relationship between an FE and a vocational rehabilitation expert (VE) is that the VE provides the FE with differentiations of a postinjury earning capacity scenario from a preinjury scenario in a personal injury case, so that the FE can estimate the present value of lost earning capacity and perhaps other categories of economic damages.”
- · CASE SCENARIOS & REVIEW
Hypothetical case scenarios and subsequent reviews are offered below for illustrative and educational purposes regarding evidence-based earning capacity assessments:
- o Case Scenario #1 (Herniated Discs Secondary to a Slip & Fall)
A 55-year female was evaluated by a Forensic Vocational Rehabilitation Consultant (FVRC) secondary to a slip and fall that caused herniated discs for both her lumbar and cervical spine. After multiple spine surgeries and the establishment of Maximum Medical Improvement (MMI), the evaluee continued to report cervical, lumbar and right leg pain, as well as moderate to severe functional deficits. She was not actively working. The FVRC did not review the evaluee’s past tax records, testimony or employment file information during his analysis. The FVRC concluded based upon his professional experiences and assessment, the evaluee was physically unable to work and earn a gainful wage within the economy. He specifically indicated the evaluee was physically incapable of functioning at the United States Department of Labor’s (USDOL) Sedentary strength level for a full-time or part-time occupation within the open labor market. A treating or evaluating physician had not issued any medical conclusion regarding the evaluee’s work capacities. Also, the FVRC concluded it was likely the evaluee would have worked until the age of 85, had the fall not occurred, as a Registered Nurse (RN), receiving wages at the 90th percentile for the occupation nationally throughout her remaining career. However, the evaluee had only demonstrated maximum mean annual earnings as a Registered Nurse (RN) in her region before the fall. The FVRC did not make any reference to published work-life expectancy data before rendering his opinions.
- o Review of Case Scenario #1
The case scenario has multiple professional errors and omissions. The FVRC did not have the necessary medical foundation to support his independent conclusion that the evaluee had physical capacities that were functionally below USDOL Sedentary strength. Physical capacities are determined by appropriately licensed health care providers and are certainly beyond the scope of practice for a Rehabilitation Counselor. Secondly, the FVRC did not reference a published methodology, or any objective data, to determine past or future earning capacities for the evaluee. Lastly, the FVRC did not incorporate any objective data from an empirical source to define the evaluee’s work-life expectancy. Due to the nature and extent of these professional errors and omissions, the FVRC would not be able to derive reliable and valid evidence-based earning capacity conclusions for the evaluee.
- o Case Scenario #2 (Traumatic Brain Injury Secondary to a Motor-Vehicle Accident)
A 45-year-old male sustained a Mild Traumatic Brain Injury (M-TBI) secondary to a motor-vehicle accident (MVA). The MVA and M-TBI resulted in mild deficits related to concentration, attention and processing speed for the evaluee, as described within the treating physician’s records and confirmed through valid neuropsychological testing by a qualified Neuropsychologist. A Forensic Vocational Rehabilitation Consultant (FVRC) was requested to complete an earning capacity assessment of the evaluee. The FVRC completed an onsite assessment of the evaluee with standardized testing. She subsequently consulted with the treating Brain Injury Physiatrist and the evaluating Neuropsychologist regarding the evaluee’s overall capacities for future work. The consult findings were documented through signed summaries from the health care providers and included into the earning capacity assessment report. Also, the FVRC noted that she followed the peer-reviewed and published RAPEL methodology during completion of her earning capacity assessment and documented the same methodological process within the report. The evaluee’s employment files and taxes for multiple years (both before and after the MVA) were reviewed. Published USDOL employment and wage statistics were analyzed for the evaluee’s region and included within the earning capacity assessment report. A standard Transferability of Skills Analysis (TSA) was performed to define the evaluee’s employability. Published and peer-reviewed work-life expectancy data was gathered and included in the report. Based upon all the assessment, data and information researched and analyzed, the FVRC rendered conclusions pertaining to the evaluee’s partial loss of wage-earning capacity after the accident, and she quantified the specifics of the earning capacity loss through her report. The findings from the FVRC were subsequently reviewed by an evaluating Forensic Economist (FE) who applied present-value calculations to the data and earning capacity conclusions reached by the FVRC.
- o Review of Case Scenario #2
The earning capacity evaluation process described above followed accepted standards, methods and data requirements necessary to facilitate arrival at evidence-based earning capacity conclusions for the evaluee. Specifically, the FVRC utilized an accepted published methodology, objective data, appropriate analysis tools, statistics and necessary medical/clinical foundation to reach informed conclusions regarding the evaluee’s earning capacities.
SUMMARY & CONCLUSIONS
Life Care Planners and Forensic Vocational Rehabilitation Consultants have similar categorical requirements for the production of their evidence-based evaluation reports. Life care plans and earning capacity assessment reports both require the utilization of an accepted published methodology and the utilization of objective data, research and guidelines to objectively substantiate the professionals’ overall conclusions. Moreover, both the Life Care Planner and the Forensic Vocational Rehabilitation Consultant must rely upon an appropriate health care foundation when specific determinations necessary for their opinion formation are outside of their professional scope(s) of practice. Finally, these two types of damage experts must apply the parameters of informed clinical judgement/opinion formation to reach objective conclusions within their scopes of practice. The utilization of life care planning and earning capacity assessment experts well-versed in necessary evidence-based practice requirements is critically important to the establishment of valid and reliable damage conclusions after an injury and/or a chronic health condition has occurred. The Life Care Planner or Forensic Vocational Rehabilitation Consultant that does not adhere to established evidence-based parameters for the determination of their conclusions places their forensic work product in jeopardy of not being accepted into the evidentiary record.