"Activities of Daily Living"--exact science or subjective?

Non-investing personal finance issues including insurance, credit, real estate, taxes, employment and legal issues such as trusts and wills.
Post Reply
Topic Author
seattlereader
Posts: 94
Joined: Tue Dec 11, 2007 8:24 am

"Activities of Daily Living"--exact science or subjective?

Post by seattlereader »

I'm being initiated into the many challenges of eldercare for the first time.

my elder entered assisted living naively interpreting that the long term care policy would be a financial aid. This was a result of reading about ability/inability to perform some of the activities of daily living outlined in the policy. many of these tasks seemed to require substantial assistance and direction for my elder(in the view of the uninitiated). it seemed obvious.

The primary care physician did not sign the insurance papers accordingly and the claim was denied.

i'm suddenly studying up on so many topics of eldercare while keeping my own personal life intact--any insights from others who have been down this road would be valuable.

is the failure to perform 2 of the activities (triggers, it seems in insurance jargon) highly subjective or is there a common standard among physicians for analyzing these triggers?

if it is highly subjective with variation among physicians, or does one go so far as to change physicians? (it is not a coveted relationship, just one of those random clinic assignments after a retirement, and we feel we hardly even know the doctor.)

can a physician in a short appointment truly assess the elders abilities without viewing day to day struggles in the living environment? after discussion and illumination from extended family regarding the day to day life of the elder, the can the doctor change his/her mind? does the insurance company look askance at this change?

did your insurance company follow up on the doctors screening with additional in person screening with an employee from the insurance company ? (my elder has a natural inclination to assert higher ability to others, then fall apart in private.)

i've read all the threads i can find here on Long Term Care, and they tend to dwell on "to buy/not to buy". But i found little about experiences of insured families struggling with the "gatekeeping" of these Activities of Daily Living, and successes and failures of appeal with helpful follow up information. (the insurance company is sure not going to be an advocate for a successful appeal...)

Thank You!
User avatar
Pajamas
Posts: 6015
Joined: Sun Jun 03, 2012 6:32 pm

Re: "Activities of Daily Living"--exact science or subjective?

Post by Pajamas »

Did you talk to the primary care physician to understand why he or she does not think assistance was needed?

Sometimes it could be obvious that assistance is needed in a short visit, sometimes it might not be. For instance, if the patient needs assistance moving from a sitting to standing position and back again, the patient won't be able to use a toilet without assistance or at least assistive devices and bathing is going to be a problem, too. If the patient cannot stand for a few minutes, assistance with meal prep will be needed. Sometimes supervision is needed for safety for certain activities, but not hands-on assistance. There might be a balance problem not evident without a particular assessment for it. The patient's blood pressure might drop when they change position and that might not be evident without a particular assessment.

The first step would be to determine exactly what the insurance company requires in certifying a need for assistance with ADLs. Is there a particular form? Are there detailed descriptions of the ADLs and the level of assistance needed? Does it require that the primary care physician make the assessment? Could a physical therapist or occupational therapist do the assessment? Could a physiatrist (physical medicine and rehabilitation doctor) do it?

If it would satisfy the insurance company's requirements, you could make an appointment with a physical or occupational therapist or a physiatrist for a detailed assessment of ADLs and to certify the level of abilities and assistance needed. Specific, detailed assessments are very helpful.
Mudpuppy
Posts: 7409
Joined: Sat Aug 27, 2011 2:26 am
Location: Sunny California

Re: "Activities of Daily Living"--exact science or subjective?

Post by Mudpuppy »

seattlereader wrote:The primary care physician did not sign the insurance papers accordingly and the claim was denied.
Back to basics first. Did the physician not sign the paperwork because the physician disagreed with the assessment or did the paperwork just never get completed (or never made it back to the insurance)?

You said this was a random physician assignment at clinical practice, and my experience is you have to be persistent with getting paperwork completed by busy practices. Paperwork can fall through the cracks. The insurance might have also sent the request to the wrong department and it may never have made it to the physician.

Followup with the insurance and clarify if the request was denied by the doctor or the insurance just gave up on getting a response from the doctor.
User avatar
Cyclesafe
Posts: 1474
Joined: Wed Dec 31, 2014 12:03 pm

Re: "Activities of Daily Living"--exact science or subjective?

Post by Cyclesafe »

Start over and have your elder examined by a gerontologist. He/she will be familiar with all the issues you are asking about. Unfortunately, if your elder is not eligible now, it will only be a matter of time before he/she will be.

The assisted living facility we used itemized services. When the services started accumulating and started including ADL qualified ones, well, what could anyone say? The doctor only confirms.....

Sounds like your elder may have "jumped the gun" on entering assisted living. But it is far better to be too early than too late, I can assure you.
"Plans are useless; planning is indispensable.” (Dwight Eisenhower) | "Man plans, God laughs" (Yiddish proverb)
epictetus
Posts: 796
Joined: Sat Mar 10, 2007 5:43 pm

Re: "Activities of Daily Living"--exact science or subjective?

Post by epictetus »

would suggest either having the MD refer your relative to an occupational therapist for an eval or have your relative see a geriatric MD or a physiatrist (physical medicine and rehab MD) who would hopefully do a more detailed assessment him/herself and/or refer your relative to an occupational therapist

the occupational therapist would actually have your relative do the tasks in question and see performance versus asking if there are problems with performing the tasks. there are standardized ways they complete tasks and evaluate functioning.
Focus on what you can control
mac_guy
Posts: 210
Joined: Thu Mar 12, 2015 2:37 pm

Re: "Activities of Daily Living"--exact science or subjective?

Post by mac_guy »

I have a relative who had a problem receiving LTC benefits. My uncle broke his hip a few years ago. After surgery, his mobility was greatly reduced. He needed a walker with him most of the time and had great difficulty with stairs.

So, he decided to move into an assisted living facility. He had a fairly generous LTC policy and decided to try and use it. We hired an elder care attorney to advise and go through the application process.

On the application, we stated that the two activities of daily living that he required assistance with were bathing and dressing. We thought this was a clear cut case. Assistance with dressing and bathing was included in the care my uncle received in the assisted living facility and my uncle deemed that assistance necessary. I also remember that medical records from his long time family care physician had to forwarded.

So, an insurance company nurse came out to talk to and examine my uncle. My uncle explained that he needed assistance dressing and bathing. A few weeks later, we get a letter from the insurance company stating benefits had been DENIED. They agreed that he needed assistance with bathing but not dressing. Since he only needed assistance with one activity, (and not two) he was denied.

We got his elder care attorney involved again and filed an appeal. The insurance company nurse was dispatched again to examine my uncle for the appeal. This time, the attorney was present for that examination.

On appeal, my uncle was approved for benefits. The whole issued turned on a technicality. It turns out that my uncle needed assistance with dressing only for a very specific piece of clothing. In this case, it was compression socks, which were required for another medical condition he has. It was very difficult for my uncle to put compression socks on and he was getting assistance with that. He could do all his other dressing, however.

It turned out that the assisted living facility had failed to note that my uncle was getting assistance with compression socks in the letter they wrote to the insurance company detailing my uncle's care plan. Our lawyer found this discrepancy and had it corrected.

So, basically, for a tiny error my uncle could have been denied LTC benefits. It seems crazy, but a tiny clerical error could have cost my uncle the ability to use $500K in insurance benefits. With the benefits approved, he is in good financial shape. Insurance benefits pay 100% of his living expenses. He is able to save his SS. If he ever uses up all his LTC benefits, he has plenty of other assets to use.

So, I guess my advice would be to hire an experienced elder care attorney. When I saw the initial denial letter, I just assumed there was nothing more that could be done. Without an attorney, he would never have received benefits.
mtnlover
Posts: 263
Joined: Mon Jul 14, 2014 8:50 am

Re: "Activities of Daily Living"--exact science or subjective?

Post by mtnlover »

When MIL went onto Assisted Living and we made application for benefits under her LTC insurance, the insurer sent a nurse out to the facility to evaluate her. I was present for that evaluation, and she was definitely "on" that morning, and I wasn't sure if the would qualify for benefits at that time. Fortunately, the insurer's nurse also checked her medical records (Alz. diagnosis) and also the records of the facility which documented the ADLs she needed assistance with. Her application was approved. No lawyers or other extraordinary efforts needed. I would suggest that in-person evaluation, records of assistance needed and medical records are the 3 factors that you should ask the insurer to consider.
JKD GUY
Posts: 38
Joined: Sun Aug 16, 2015 1:00 pm
Location: Nomad

Re: "Activities of Daily Living"--exact science or subjective?

Post by JKD GUY »

seattlereader wrote:
is the failure to perform 2 of the activities (triggers, it seems in insurance jargon) highly subjective or is there a common standard among physicians for analyzing these triggers?

Speaking from the view of an Occupational Therapist, it is meant to be standardized. Meaning, there are assessment tools used for therapists to evaluate the patient. One of which is: Functional Independent Measure (FIM) which is widely used at inpatient rehab settings. Many other settings use a less formal way of assessing patients based off the FIM. For each ADL there is an objective criteria from which the score is derived. So, it is objective according to what the patient is able to do functionally. However, it becomes more subjective if the therapist does not score it properly. I see it everywhere I work.
"Dishonest money dwindles away, but whoever gathers money little by little makes it grow" Proverbs 13:11
Katietsu
Posts: 7676
Joined: Sun Sep 22, 2013 1:48 am

Re: "Activities of Daily Living"--exact science or subjective?

Post by Katietsu »

Check to see if the assisted living facility did an assessment and care plan. If your elder is in the assisted living facility, they should be able to give you the best information on your elder's abilities. In my experience, all of elder care is focused on ADL's, so the assisted living facility should be able to discuss in those terms with you. They may also have a social worker or other staff member that can advise you on obtaining LTC benefits. The tax deductibility of assisted living is also tied to the assesment and care plan and ADL's. If a tax deduction is to be sought you need to obtain the documentation asap.

The terminology that I became familiar with during my foray into eldercare evaluations centered around the amount of assistance needed from a "helper(s)" to complete the task. It can be very painful for a family member to watch the amount of effort and time required by the the elder to complete a formerly easy task. However, in my case, the elder was still be considered to have the ability to perform that task because they did complete the task without the assistance of a second person. After one inpatient rehab experience, an elder was deemed able to perform all ADL's even though the discharge instructions recommended that the elder either enter an assisted living facility or have full time home supervision.
Topic Author
seattlereader
Posts: 94
Joined: Tue Dec 11, 2007 8:24 am

Re: "Activities of Daily Living"--exact science or subjective?

Post by seattlereader »

THANK YOU ALL for these highly informative replies. I feel i have vaulted over the uninitiated stage in short order with your isights, and key words such as occupational therapist, Functional Independent Measure, consultation with eldercare attorney, physiatrist (not a misspell--see below), gerontologist, tax deductibility (hadn't thought of that) , and consulting the assessment and care plan of the assisted living facility. these keywords provide so much more in depth reading than my prior searches revealed when i just searched :Activities of Daily Living...

Mudpuppy: yes the doctor did complete the insurance form to assess the ADL's; my comment about the clinic was to describe the seeming loss of individuality and acquaintance with a doctor, especially for a sr who had previously grown up with the old time doctor as acquaintance. But can that doctor who arrives into the room with the patient already seated and prepped by the assistants know, in brief seated semi-annual checkups, what a sr can and can't do when the patient hardly leaves the chair?

it seems that my exchanges with the LTC Insurance adjustor rises in depth of content as i become more informed. Your replies have provided a better view for formulating either appeal, or a new claim in the future when we see his ADL's drift into the now more fully understood framework of how they are assessed.

With appreciation, Seattlereader
DTSC
Posts: 1194
Joined: Mon Oct 20, 2008 9:47 am
Location: Illinois

Re: "Activities of Daily Living"--exact science or subjective?

Post by DTSC »

seattlereader wrote:I'm being initiated into the many challenges of eldercare for the first time.

my elder entered assisted living naively interpreting that the long term care policy would be a financial aid. This was a result of reading about ability/inability to perform some of the activities of daily living outlined in the policy. many of these tasks seemed to require substantial assistance and direction for my elder(in the view of the uninitiated). it seemed obvious.

The primary care physician did not sign the insurance papers accordingly and the claim was denied.

i'm suddenly studying up on so many topics of eldercare while keeping my own personal life intact--any insights from others who have been down this road would be valuable.

is the failure to perform 2 of the activities (triggers, it seems in insurance jargon) highly subjective or is there a common standard among physicians for analyzing these triggers?

if it is highly subjective with variation among physicians, or does one go so far as to change physicians? (it is not a coveted relationship, just one of those random clinic assignments after a retirement, and we feel we hardly even know the doctor.)

can a physician in a short appointment truly assess the elders abilities without viewing day to day struggles in the living environment? after discussion and illumination from extended family regarding the day to day life of the elder, the can the doctor change his/her mind? does the insurance company look askance at this change?

did your insurance company follow up on the doctors screening with additional in person screening with an employee from the insurance company ? (my elder has a natural inclination to assert higher ability to others, then fall apart in private.)

i've read all the threads i can find here on Long Term Care, and they tend to dwell on "to buy/not to buy". But i found little about experiences of insured families struggling with the "gatekeeping" of these Activities of Daily Living, and successes and failures of appeal with helpful follow up information. (the insurance company is sure not going to be an advocate for a successful appeal...)

Thank You!
ADL's include:
Dressing
Bathing
Eating
Walking
Toileting
Hygiene
Transferring

Instrumental activities of daily living (IADL's) include:

Housework
Preparing meals
Taking medications as prescribed
Managing money
Shopping for groceries or clothing
Use of telephone or other form of communication
Transportation within the community

As a primary care physician, it's possible to make the assessment of whether someone is independent of their ADL's within minutes (seconds!). If you see a wheelchair outside the exam room, it's already a good tip off even before you see the patient (though sometimes patients can walk short distances). If you ask the patient to get up out of the wheelchair without assistance and they cannot, then there's your answer. How can they be expected to get into a shower and bathe themselves when they cannot stand steadily on their own?

Having said that, many patients are not independent of ADL's and IADL's but are still able to live on their own if they have good support. If their major deficit is bathing, a family member helping them bathe several times per week and dropping off prepared meals might just be enough support.
User avatar
Shackleton
Posts: 947
Joined: Mon Dec 29, 2014 5:20 pm

Re: "Activities of Daily Living"--exact science or subjective?

Post by Shackleton »

To contrast what DTSC posted, when my mom first went into AL, she didn't use a walker, could dress/bathe herself, could hold short conversations just fine (and still had a very extensive vocabulary) and was what I called a "highly functioning dementia patient" because she would fool people by how interactive she was. But when evaluated by a neuropsychiatrist she scored at the 4th percentile for reasoning and about 10th percentile for memory. During a short conversation, she could pretty much "fake it" especially when speaking to someone like a doctor (who she respects and therefore doesn't want to seem deficient in front of him) by giving what seemed like perfectly reasonable answers to questions. But the answers were all just made up to give the impression that she knew what she was talking about. So my mom's doctor probably would have said she was fine to be in independent living based on those short conversations/questions they have during checkups. But during a more detailed and specific evaluation of ADLs (our LTC insurance company had an OT do the evaluation, which was very thorough) it was clear she belonged in AL.
“Superhuman effort isn't worth a damn unless it achieves results.” ~Ernest Shackleton
DTSC
Posts: 1194
Joined: Mon Oct 20, 2008 9:47 am
Location: Illinois

Re: "Activities of Daily Living"--exact science or subjective?

Post by DTSC »

Shackleton wrote:To contrast what DTSC posted, when my mom first went into AL, she didn't use a walker, could dress/bathe herself, could hold short conversations just fine (and still had a very extensive vocabulary) and was what I called a "highly functioning dementia patient" because she would fool people by how interactive she was. But when evaluated by a neuropsychiatrist she scored at the 4th percentile for reasoning and about 10th percentile for memory. During a short conversation, she could pretty much "fake it" especially when speaking to someone like a doctor (who she respects and therefore doesn't want to seem deficient in front of him) by giving what seemed like perfectly reasonable answers to questions. But the answers were all just made up to give the impression that she knew what she was talking about. So my mom's doctor probably would have said she was fine to be in independent living based on those short conversations/questions they have during checkups. But during a more detailed and specific evaluation of ADLs (our LTC insurance company had an OT do the evaluation, which was very thorough) it was clear she belonged in AL.
A 30 question Mini-Mental State Exam can be administered in 10-15 minutes can be used to screen for dementia, such as in your mother's case. (Do primary care doctors get enough time to do this often enough? No - not if you have to worry about their diabetes, heart problems, knee pain and the lump on their back)

However, it's not uncommon to see high functioning dementia patients still living independently. If they are physically well and live close to a grocery store and can negotiate the short drive/walk to buy food, they can go for months and years. If they had previously set up direct deposit of their Social Security check to the bank and can go get cash and pay for everything with cash, complex financial transactions can be avoided. (I had a patient who was found to be demented by his longtime banker when they could not decipher his handwriting - he had a stroke affecting his language area in between appointments with me). Many dementia patients do OK as long as they are not moved out of their element. They decompensate when they have to learn something new. It would not be surprising that the old lady 3 pews in front of you in church suffers from mild dementia. But she's been going to the same church for 30 years and can still recognize how to get there.

I wonder how your mother managed her finances? I imagine that eventually she would have been "found out" when she lapsed on more complex activities, such as paying the utility bills. Your mom might have been someone who could have stayed in her own home for a while if a family member were able to help her handle more complex activities which occur intermittently, such as paying annual property taxes.
Post Reply