Life Care Planning

Course Description:
This course introduces students to case management concepts, principles of practice, psychosocial aspects, healthcare
management, and delivery, healthcare reimbursement and rehabilitation. It uses the Case Managers Scope of Practice
criteria to assist in developing a Life Care Plan for a patient. Included will be patients with congenital complications,
chronic illnesses, and complex injuries throughout the life span. Precertification exams will be employed to assist in
preparation for Certification as a Case Manager.

Program Outcomes

Compose a plan, which evaluates the established outcomes and facilitates the termination of care
Demonstrate principles of advocacy both for the client and in the promotion of client self-advocacy

Course Objectives

Examine Nurse Case Management concepts including coordination of care and reimbursement for general and
vulnerable populations
Evaluate the utilization of case management plans, critical pathways, evidence-based practice and protocols
Synthesize the concepts of multiculturalism, ethics, and principles that underpin life care planning
Analyze the psychosocial aspects of life care planning
Create a life care plan based upon the Scope of Practice criteria for Case Management
Develop a plan to complete precertification activities needed to sit for Certification

Course Credits: 3 credits

Course Textbook(s):

Fattorusso, D. & Quinn, C.E. (2012). A Case Managers Study Guide: Preparing for Certification, (4th ed.). Jones &
Bartlett Learning. ISBN: 9781449683351

Mullahy, C. (2017). The Case Managers Handbook (6th ed). Burlington, MA: Jones & Bartlett Learning. ISBN:
9781284102406 (used in prior course)

Supplemental Materials:
Standards of Practice for Case Management: FREE DOWNLOAD:
http://solutions.cmsa.org/acton/media/10442/standards-of-practice-for-case-management
American Association of Nurse Life Care Planners: http://www.aanlcp.org/?
Publications Life Care Planning: http://www.paulmdeutsch.com/LCP-introduction.htm
Journal Article: Johnson, C. B., Lacerte, M., & Fountaine, J. D. (2015). Certification standards of professionals
coordinating life care plans for individuals who have acquired brain injury. Neurorehabilitation, 36(3), 235-241.
doi:10.3233/NRE-151212: permalink:
http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=109468821&site=ehost-live
Standards of Practice for Life Care Planners. (2006). Journal of Life Care Planning, 5(3), 123-129. Permalink:
http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=106204792&site=ehost-live

Prerequisites: Nursing courses must be taken in the prescribed order listed in the University Catalog.

Rubrics are utilized to grade each of these items and are linked with the assignment and discussion details. A course
grade is determined based on the percentage of points as designated in the following chart.

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 Assessment Percent of Final Grade
Discussions 17%
Assignments 30%
Practice Exams 20%
ePortfolio Assignment 3%
Final Project 30%

Below is an at-a-glance look at the weekly course content. In each Getting Started module within the course, you will
find details about your weekly readings, lectures, supplemental resources, discussions and assignment instructions, and
rubrics. You must respond to at least two colleagues posts if there is a discussion question post.
TOPICAL OUTLINE BY WEEK
Week 1:

Readings/Viewings: Read Chapter 2 (pp 19-44) in Fattorusso

Standards of Practice for Life Care Planners. (2006). Journal of Life Care Planning, 5(3), 123-
129.
Publications Life Care Planning

Discussion: Using the code in the front of the Fattorusso text, follow the directions to access the online website
and enroll. Generate the Pretest and complete it. After completion discuss your feelings about the
exam.

Assignment(s): After completing the readings for this week (particularly the steps to Life Care Planning: Publications
Life Care Planning http://www.paulmdeutsch.com/LCP-introduction.htm) begin conceptualizing what
will become your Life Care Plan at the end of the course. Reflect on a particularly difficult patient
scenario that you have encountered as a nurse. Write a formal, scholarly paper. Briefly summarize the
case with an introduction. Address each of the weekly objectives using level two headings.

Week 2:

Readings/Viewings: Read Fattorusso Chapter 3 (pp 67-87)

Read Mullahy Chapter 12 (pp 307-322), and Chapter 29 (pp 625-646)

Discussions: 1. Review the rest of the tabs in the School of Nursing Global Village for new information. You
will review the FAQs. Please know you may send a question to nursing@grantham.edu.
Discuss something new you have learned in the Global Village.
2. Choose a complex case in your professional history that required case management. Identify
the vulnerable population and explore your feelings about this population. What multicultural
aspects were in this situation? Analyze the underlying ethical issues in your case. Discuss the
outcomes of your case.

Assignment(s): 1. Review the legal aspects in Case Management (Fattorusso, pp 67-87). Create a plan to avoid
legal issues in Life Care Planning. This is not a formal paper and may be in any format that
illustrates the legal issue and your plan to address it.
2. Access Your Navigate TESTPREP from week 1. Choose 50 questions from Chapter 3: Principles
of Practice. Submit a snippet/screenshot of your final score.

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Week 3:

Readings/Viewings: Read Fattorusso Chapter 4 (pp 129-141)

Read Mullahy Chapter 30 (pp657-667), and Chapter 32 (pp 687-693)

Discussions: 1. After completing the readings, keep a diary for three days. Identify behavioral health issues in
those with which you come into contact. Reflect upon the different types, manifestations, and
their effect on health. How might you use R.U.L.E. in mental health coaching?
2. Identify a friend or relative for which to complete a Spiritual Health History (Fattorusso p 147).
Complete the history using the S.P.I.R.I.T. form on p.147. Share your S.P.I.R.I.T. form. Discuss
how you will incorporate this Spiritual Health History into your life care plan.

Assignment(s): 1. Follow each step outlined in Chapter 32 to complete an Integrated Model of Care (Behavioral
Health with Primary Care: An Integrated Model Mullahy pp 687-693). This is not a formal
paper. Create level two headings for each section in the chapter.
2. Access Your Navigate TESTPREP from week 1. Complete the 33 questions from Chapter 4:
Psychosocial Aspects. Submit a snippet/screenshot of your final score.

Week 4:

Readings/Viewings: Read Fattorusso Chapter 5 (pp163-176)

Read Mullahy Chapter 21 (pp 533-536), and Chapter 22 (pp 539-541)

Discussions: 1. Create a simple chart that shows the different levels of care and the case managers role in
promoting effective care transitions. Share your chart. Discuss the areas you think will be most
prone to error and why.
2. Create a new care model for the case management professional that will take you into the
future.

Assignment(s): Review the different models of case management. Choose one that you will utilize to underpin your life
care plan. Choose a patient with which you are very familiar and work through the model you have
chosen. Include risk stratification and predictive model from this weeks readings. This assignment is
not a formal paper but must thoroughly address a model applied to a patient you have chosen.

Week 5:

Readings/Viewings: Read Fattorusso Chapter 6 (pp 193-220)

Read Mullahy Chapter 15 (pp353-357), and Chapter 18 (pp 395-414)

Discussion: Case Managers may choose to become a consultant. Discuss what needs you must focus on to become
a consultant, how you will obtain those skills, and how you might market yourself.

Assignment(s): 1. Briefly describe each of the different reimbursement and payor plans for healthcare that the
case manager must be familiar with. Apply each to the model and patient from week 4.
Explain how the different payor sources would impact the life care plan.
2. Access Your Navigate TESTPREP from week 1. Complete 50 questions from Chapter 6:
Healthcare Reimbursement. Submit a snippet/screenshot of your final score.

Week 6:

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Readings/Viewings: Read Fattorusso Chapter 7 (pp 351-368)
Read Mullahy Chapter 19 (pp 423-458)

Discussion: Discuss your experiences with microsystems and macrosystems and how each affect outcomes
management. Discuss how you would adjust goals and outcomes based upon each.

Assignment: Using your identified patient/population from the prior assignment, create a chart that explores each
of the rehabilitation sections found in Chapter 7 of the Fattorusso text (Workers Compensation
Insurance, ADA of 1990, Work Hardening, Assessing the Patients Level Of Physical and Mental
Impairment, Orthosis, Prosthesis, and Assistive Devices, and Ergonomics). Utilizing this chart, Chapter
19 (Mullahy), and two articles from the library on Outcomes Assessment, create goals for each area
based upon best practice and established benchmarks.

Week 7:

Readings/Viewings: Journal Article: Johnson, C. B., Lacerte, M., & Fountaine, J. D. (2015). Certification standards of
professionals coordinating life care plans for individuals who have acquired brain injury.
Neurorehabilitation, 36(3), 235-241. doi:10.3233/NRE-151212

Discussion: 1. Access the Commission of Case Managements Body of Knowledge (CMBOK) for the End of
Life Conversation Project Toolkit (https://www.cmbodyofknowledge.com/content/toolkits). (It
is third on the list). Work through all areas of the toolkit. Discuss your comfort level at
addressing end of life issues in your Life Care Planning. How might you use this toolkit to
assist in end of life issues?
2. Does the population you are writing about for your Life Care Plan have an organization that
guides their care? If so, which organization? Assess the effectiveness of the organization in the
guidance of patient care. Was the information easy to find? Tell us about your search
including any break through you may have had while researching your project.

Assignment(s): Complete your Life Care Plan:

Select a population of interest to you. If you are unsure of your selection, check with the
instructor PRIOR to beginning the assignment.
Review each weeks content and add sections that correspond to each weeks objectives. It
will be specific to your chosen population and may require slightly different sections. There is
no maximum/minimum page count for this assignment. Each Life Care Plan is unique and will
have different requirements. It is expected that your Life Care Plan thoroughly cover your
patient.

Week 8:

Readings/Viewings: Commission for Case Manager Certification (CCMC)

American Association of Nurse Life Care Planners

Discussions: 1. The American Association of Nurse Life Care Planners is one. Visit the organizations web site:
http://www.aanlcp.org/ and explore all the areas. Sign up for the free blog, attend a free
webinar and explore Certification requirements. Discuss your future plans for certification and
what you found most useful in the site.
2. Review and reflect on what you have learned in the past eight weeks. What was the most
practical or most easily applied lesson you learned? What concepts were the hardest to grasp?
Why? Finally, how do you think you will use what you have learned in the future?

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Assignment(s): Reflect back on this course and think of ways in which the readings, discussions, and assignments
assisted in meeting these program outcomes. Did one of the course objectives come into play in
assisting you to meet these program outcomes? If so, which one and in what way? If not, why not?
Create 2-3 PowerPoint slides that reflect on the programmatic outcomes for this course. The slide
should give a brief description of the artifact(s) you have chosen and an explanation of how this
coursework helped you meet the program outcomes.

The following table outlines the academic effort required by students to be successful in this course. While the times in
the table are approximate, it is presented to help students with their time management. Please note, depending on the
student's background knowledge and experience of the course subject and an individual student's academic capabilities,
these times will vary. If you have any questions or concerns, please direct them to your instructor or student advisor.

Week Type of Activity Activity Estimated Hours Required

Readings/Lectures 0.8
Online Discussions 4.0
Assignments 0.0
1 Readings 1.5
Discussions 1.0
Preparation
Assignments 12.0
Clinical/Lab Hours 0.0

Week Type of Activity Activity Estimated Hours Required

Readings/Lectures 0.9
Online Discussions 4.0
Assignments 1.0
2 Readings 1.5
Discussions 1.0
Preparation
Assignments 8.0
Clinical/Lab Hours 0.0

Week Type of Activity Activity Estimated Hours Required

Readings/Lectures 0.9
Online Discussions 4.0
Assignments 1.0
3 Readings 1.0
Discussions 1.0
Preparation
Assignments 8.0
Clinical/Lab Hours 0.0

Week Type of Activity Activity Estimated Hours Required

Readings/Lectures 0.7
Online Discussions 4.0
4
Assignments 0.0
Preparation Readings 0.6
5
 Discussions 1.0
Assignments 9.0
Clinical/Lab Hours 0.0

Week Type of Activity Activity Estimated Hours Required

Readings/Lectures 0.8
Online Discussions 2.0
Assignments 1.0
5 Readings 1.9
Discussions 0.5
Preparation
Assignments 8.0
Clinical/Lab Hours 0.0

Week Type of Activity Activity Estimated Hours Required

Readings/Lectures 0.5
Online Discussions 2.0
Assignments 0.0
6 Readings 1.9
Discussions 0.5
Preparation
Assignments 12.0
Clinical/Lab Hours 0.0

Week Type of Activity Activity Estimated Hours Required

Readings/Lectures 0.7
Online Discussions 4.0
Assignments 0.0
7 Readings 0.2
Discussions 1.0
Preparation
Assignments 12.0
Clinical/Lab Hours 0.0

Week Type of Activity Activity Estimated Hours Required

Readings/Lectures 0.6
Online Discussions 4.0
Assignments 0.0
8 Readings 0.7
Discussions 1.0
Preparation
Assignments 5.0
Clinical/Lab Hours 0.0

Follow this link for course-related Policies and Contact Information.

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