Before I describe what I do, let me tell you what I am, which is first, last and always a nurse.
I earned my bachelor's of science in nursing in a college that demanded a high level of professionalism, problem-solving skills and scientific rigor. I earned my master's in nursing degree in a challenging thesis program with no online components.
I was a critical care nurse in world-class academic medical centers. I enjoyed a number of good opportunities with this because I had earned my master's degree.
So naturally I changed fields and worked for 16 years in case management, first in field workers' compensation and then as an in-house hospital case manager across the continuum of care for a large medical practice with an HMO shared-risk agreement.
Along the way I also did stints as a hospice liaison/nurse legal consultant in a medical malpractice law firm; "revenue enhancement officer" in a gritty urban hospital (meaning, I begged HMOs for reimbursement); HMO nurse (meaning, I refused reimbursement); and others.
In each of those positions I worked with and learned from many attorneys, claims professionals, physicians, therapists, facilities and, ultimately, sick and injured people.
And now, I am a Certified Nurse Life Care Planner (CNLCP).
The Life Care Plan (LCP) is a tool used by the CNLCP to estimate medical and nonmedical needs of a person with a catastrophic injury or chronic illness over an estimated lifespan. Like every nursing plan of care, it's designed to be dynamic. It's based on published standards of practice, comprehensive assessment, data analysis and research.
LCPs may include medical needs and costs, such as physician and nursing care, medication, and therapies; and also less-obvious things like goods and services to help with safe aging in place, architectural modifications, change in level of care anticipated, equipment/transportation/furnishings, i.e., anything that will incur costs related to the injury or illness.
Many LCP cases deal with people involved in workers compensation or liability claims with catastrophic conditions like traumatic brain injury, spinal cord injury, major trauma, major burns, chronic pain, major psychiatric diagnoses, or a combination of conditions.
The contents of a LCP may be comprehensive or modified based on the needs of the party making the request. This is generally a plaintiff attorney seeking to obtain funds for a person's needs; a defense attorney for an insurance carrier seeking to limit damages or to verify a plaintiff plan; or a trust officer whose charge is to manage funds for lifetime care.
All of these clients need and want our nursing expertise to explain the medical records and what they mean.
The American Nurses Association recognizes nurse life care planning as part of the legal nursing specialty practice area. As registered nurses, we do not use the medical model; our practice is based on the nursing process and nursing diagnosis.
A CNLCP is an RN with a minimum of 5 years of clinical experience who has particular education and expertise in preparing and reviewing LCPs, including medical record review, research, legal aspects, and particular course content on common conditions often requiring an LCP.
Some of us work as in-house consultants for insurance companies or law firms. Like most CNLCPs, however, I run my own business.
CNLCPs also see children with birth injury or other developmental condition, like cerebral palsy or mental disability, or elders whose care needs all two-family or a trust fund and may not involve litigation.
In terms of experience and education needed to be a CNLCP, a broad background in nursing, preferably with a degree(s) from an accredited college or university nursing program, is essential for assessing the injured person's function, cognition, and current situation.
The CNLCP holds a current, unrestricted RN license, has education and experience in case management and life care planning, and has passed the national examination to demonstrate competence. Other certifications, such as in rehabilitation nursing, case management, disability management, legal nurse consulting, and/or other nursing specialty will testify to the nurses breadth and depth of expertise.
For more information on certification, including links to courses to prepare you for the role and certification examination, please go to the American Association of Nurse Life Care Planners (AANLCP) website at http://www.aanlcp.org/. The AANLCP has an annual educational conference brimming with strong professional nurses. It's a very collegial group. You do not need to be a CNLCP to join the association or to attend the conference. Join us in Philadelphia next November!
Privileges & Limitations
RNs with the CNLCP credential are permitted, and, in most jurisdictions are mandated to diagnose and treat human responses to illness by virtue of their professional licensure, a privilege we share only with physicians and which we do not take lightly.
Parenthetically, if you haven't looked at the NANDA-I since nursing school, and the idea of nursing diagnosis makes your eyes cross, I commend the current edition, 2012-2014, to your attention. Along with the ANA Scope and Standards of Practice it confers an impressive amount of power to those who choose to take hold of it. When we defend our expertise in the legal system, it stands right behind us.
I hold certifications in rehabilitation nursing, case management and life care planning. My professional licensure, certification, experience, education, standards of practice, and ethics are backed by the nurse practice act, which mandates every RN to prescribe a plan of care after assessing the patient's response to injury or illness. Therefore, the evaluations and other aspects of my plan are, in fact, within my professional RN licensure to prescribe.
"You're a nurse though, so you can't prescribe, can you?" is a question I hear. Although as a CNLCP I collaborate with members of the treating team and many other specialists (like neuropsychologists, driving safety professionals, NARI/CAPS-certified home modification professionals, home and long-term health providers, and recreational therapists, to name a few), most life care plan components will not be involved with a health insurance contract and do not require physician signature to implement.
My favorite thing is that my work allows me to use everything I have learned and done in my career as a nurse. Although many people think that if you're not wearing scrubs you're not a real nurse, the basis for my assessments and planning is the nursing process. I rely on it to explain and justify my plan elements in many settings, notably at deposition when I hear, "Nurse Howland, you can't prescribe these things in your plan because you aren't a doctor, right?"
Heads up: There is no legal requirement in any state in the U.S. for all goods and services for patients care to be ordered by a physician. The law requires some things (such as medications and surgery) to be prescribed or performed by physicians or advanced practice nurses, but insurance companies only require that most goods and services be ordered by physicians or APRNs for billing purposes.
It's important not to confuse an insurance plan's requirement to have a physician prescription for a billable product or service, or the legal requirement for physicians to prescribe medication, with the nursing ability to assess that something is appropriate and indicated by nursing diagnosis.
Medical plans of care are developed by physicians; nursing plans of care are developed by registered nurses. Prescribing a nursing plan of care is precisely what nurse life care planners do.
Most of my plaintiff clients are private-pay if they win their cases; medical equipment companies, therapy centers, and other providers will be happy to address their needs without physician prescriptions if a health insurance company is not the payor.
Case by Case
One of the things I love about being a nurse life care planner is that I rarely do the same thing every day. Every case is different.
I may be reviewing medical records to find out what the mechanism of injury was for a catastrophic case, like a spinal cord injury or brain injury, and then what the person's functional ability is, so I can start thinking about levels of care, or home modification, or adaptive equipment.
I might be on a conference call with an attorney and client to explain what the medical findings are and what they mean. I might be traveling to a patient's home to do an assessment and some patient teaching. I might be attending a team meeting at a rehabilitation facility.
I might be being deposed, to explain how I decided what provisions to make for components in my plan, or be asked to testify at trial to explain why the elements of the plan are necessary for the health and safety of the ill or injured person if mediations don't produce a settlement.
I might be at an educational offering, learning about a new technology for adaptive communication or the latest in computerized prostheses. I might be reviewing a plan from a plaintiff's life care planner to be sure it's accurate and that the numbers add up. I might be collaborating with a colleague on a thorny issue.
Or, I might be sitting at my desk in the office in my house, comfortably dressed with a cup of tea and some pleasant music in the headphones, researching, writing, and editing a life care plan before I send it to the client for review.
Making a Difference
I believe nursing will be more important than ever in the coming decades, as the population ages, as practicing medicine becomes less fun and less lucrative.
Research continues to document that outcomes and patient satisfaction in chronic illness and wellness care are higher with advanced nurse practitioners than physicians.
As more of us are marketing our nursing skills in business - I use nursing diagnosis every day, and this precisely is why my clients hire me - we can have a positive effect on decision-makers by showing them how smart we are, and how the nursing process is a living schema with a solid scientific base that we use to benefit patients in unexpected, nontraditional ways.
Another of the things I like most about my work is that it lets me use every bit of that past nursing work experience. I am thankful that a little grey hair overlying the little grey cells is an advantage. But as my office assistant said after seeing me in action, "This isn't a game for rookies."
Wendie Howland is owner and principal of Howland Health Consulting based in Massachusetts and offering life care planning, legal nurse consulting and case management in the U.S., Canada and the Caribbean, and editor of the Journal of Nurse Life Care Planning, the official publication of the AANLCP. Contact her at firstname.lastname@example.org; 866-604-9055; or via her website at www.howlandhealthconsulting.com.