8330 S. Madison St., Suite 90 Burr Ridge, IL 60527 ph 630.953.2154 fx 630.953.2155 www.lcius.com

North Shore Office Denver Office 100 S. Saunders Rd., Suite 150, Lake Forest, IL 60045 304 Inverness Way South, Suite 135, Englewood, CO 80112 TEL: 847-857-9133 FAX: 630-953-2155 TEL: 303-495-4379 FAX: 866-816-2908

Life Care Plan Review

June Cleaver

January 30, 2015

Prepared by: Patricia Cline, LCSW, CCM, CASWCM, NCG, MSCC

Expert Lifecare Manager

Shay Jacobson, RN, MA, CNLCP, LNCC, NMG Expert Lifecare Manager

President, Lifecare Innovations

June Cleaver

Table of Contents Synopsis p. 2 Sources of Information p. 3 Medical Issues p. 3

Visual Impairment/ Retinitis Pigmentosa p. 3-5 Arthritis/Polyarthralgia p. 5-6 Headaches and Dizziness p. 7 Hypertension p. 7 Chronic Obstructive Pulmonary Disease p. 7 Additional Pre-morbid Medical Conditions p. 8 Accident Related Injuries p. 8 Recent Rehabilitation Related Medical Treatments p. 8-9 Status of Accident Related Injuries p. 9 Medications p. 9-10 Billingsly Life Care Plan Review p. 10 Billingsly #1-“Altered Health Maintenance” p. 11

Billingsly #2-“Impaired Physical Mobility/High Risk for Injury/Activity Intolerance” p. 11-15 Billingsly #3-“Potential for Alteration in Nutrition” p. 15 Billingsly #4-“Chronic Pain” p. 15-18 Billingsly #5-“Potential for Impaired Skin Integrity” p. 18

Billingsly #6-“Altered Bowel Elimination- Bowel and Bladder” p. 18

Billingsly #7-“Self Care Deficit” p. 18-19 Billingsly #8-“Home Maintenance

Management-Impaired” p. 20 Billingsly #9-“Sensory Perceptual Alteration/

Impaired Thought Process” p. 20 Billingsly #10-“Altered Sleep Pattern” p. 20

Billingsly #11-“Individual Ineffective Coping/ Self Esteem” p. 21

Billingsly #12-“Caregiver Role Strain, Potential/ Family Coping; Compromised/ Family Process Altered” p. 21

Billingsly’s “Future Implications” p. 21-23 Billingsly’s “Cost Projections” p. 23-26 Summary & Recommendations p. 26-27

June Cleaver

Synopsis: Lifecare Innovations (LCI) is a professional Lifecare Management organization that was asked to provide consultative services in regards to the legal case filed by Ms. June Cleaver. Ms. Cleaver is currently 78 years old and is living in an apartment in the same building as her daughter and granddaughter in Sterling, Vermont. Ms. Cleaver was a pedestrian walking near her former residence in Pittsburgh, Pennsylvania when she was involved in a motor vehicle accident with a pickup truck on October 14, 2013. She was 77 years old at the time of the accident. Lifecare Innovations’ staff was asked to review records and was provided with a complete copy of all available medical records as well as numerous depositions and medical expert reports that were provided by the Ward Greenberg law firm. LCI was also provided with a Life Care Plan prepared by Janet Billingsly that is dated July 1, 2014 and asked to provide analysis and rebuttal opinion regarding the data and proposed Life Care Plan laid out in that document. This report provides detail review of Ms. Billingsly’s Life Care Plan report in light of the available records and information. Following analysis of the Billingsly report, Lifecare Innovations’ summary opinion and recommendations for how to best address Ms. Cleaver’s ongoing care needs are provided. Sources of Information: The following were utilized in preparation of this document:

• Mercy Hospital records marked D202-342; D1235-D1243 unmarked pages 1-2120 • Pennsylvania EMS Report marked D199-201 • County Hospital records marked D343-476; D820-1181 • St. James Hospital records marked D577-806 • Graver’s Pharmacy records marked Dl566-1567 • St. James Family and Women's Health records marked D1594-1695; D1905-1995;

D2045-D2224 • Center for Urologic Care of Blue County records marked D1696-1739 • Rite Aid Pharmacy Records marked D 1761-1804 • Dr. Morris Arthritis and Osteoporosis Center Records D1861-1894 • Professional Vision Center records marked D1740-1746; D1895-1904 • Progressive Vision Institute records marked D1747-1748; D1997-2004 • Ophthalmic Consultants of Vermont records marked D2248-2257 • Easter Seals Central records marked D2258-2263 • Mercy Family Practice records marked D2881-2896 • Ester Arthritis and Osteoporosis Clinic Records marked D2247 • Dr. Arnaz letter to Dr. Stone regarding Ophthalmology visit marked D2535 • Verification of Need of Reasonable Assist by Dr. Stone marked D2543 • Dr. Lou Dobbs’s records marked D2547-D2550 • Emergency Physician Medical Record marked D 2561

June Cleaver

• Dr. Chase letter to Dr. Fisher regarding cataract extraction marked D2580 • Robbins hospital and Medical Center records marked D2742-D2744 • Physician discharge summary marked D2830-D2832 • Deposition transcripts of June Cleaver (plaintiff), Mary Anderson (granddaughter)

and Dr. Stone (plaintiffs primary physician) with associated Exhibits • Deposition transcripts of Sue Smith (primary care provider) with associated Exhibit

marked D1568-D1584; D2012-D2018; D1585; D1586-1589 • Letter from Dr. Stone regarding chronic issues marked D3309 • Housing Authority Verification of Need form regarding first floor housing marked D3619 • Plaintiffs Life Care Plan by Janet Billingsly dated 07-10-13 • Medical expert IME report and amended report by Dr. Paul Piaza, M.D. • Medical expert IME report by Dr. Joe Dutton, M.D. • Review of videotaped examination of Ms. Cleaver by Dr. Dutton • Verbal communications with Dr. Dutton • Medical expert IME report by Dr. Richard Simpson, M.D., FACS, FICS • Commonwealth of Pennsylvania Bureau of Blindness & Visual Services website and

associated links • State of Vermont: Bureau of Education and & Services for the Blind website and

associated links; Department on Aging, online services listings

Medical Issues: Ms. Cleaver is an elderly person who suffers from chronic, progressive and debilitating health conditions that have been the cause of her seeking and receiving a significant amount of medical care over the course of at least the past fifteen to twenty years. The Billingsly Life Care Plan report in some instances anecdotally acknowledges the existence of premorbid health problems, but it does not do so in a systematic fashion and it does not differentiate these pre-existing problems from problems that are directly related to the accident. Although the overwhelming majority, in fact nearly all, of Ms. Cleaver’s health problems are long standing and chronic nature, the Billingsly plan nevertheless incorporates services and costs for managing these and thereby attributes them to the accident. The medical records clearly portray details of Ms. Cleaver’s numerous historic, chronic, and ongoing health problems throughout the course of voluminous records, and in the interest of efficiency each and every health issue will not be recounted in detail in this report. Rather, the following is intended to provide a relatively succinct summary of major health problems that have been and will be progressive over time so that these may be differentiated from any accident-specific issues. Following this summary, further details will be provided on each topic as it particularly pertains to content within the Billingsly Life Care Plan report. Visual Impairment/ Retinitis Pigmentosa: It is important to consider that Ms. Cleaver has been suffering from retinitis pigmentosa for many decades and that this is a progressive, genetic eye disease. There is no effective treatment and no cure, and Ms. Cleaver vision will most likely continue to

June Cleaver

deteriorate. Ms. Cleaver received her high school education from the Catholic Guild for the Blind, completing that via attainment of a GED. Records generated by Eye Doctors Associates in 1994 indicate that Ms. Cleaver was diagnosed with retinitis pigmentosa seven years prior at the New Jersey Eye and Ear Institute and Rochester University. Records from Progressive Vision Institute in Pennsylvania from 2011and from Professional Vision Centers in 2014, as well as a recent report from Dr. Richard Simpson, corroborate the retinitis pigmentosa diagnosis. In 2001 when Ms. Cleaver completed disability paperwork she indicated then that she was legally blind, and her vision is documented as having deteriorated progressively since that time. Dr. Simpson indicates that Ms. Cleaver’s retinitis pigmentosa manifest in severely constricted visual fields in both eyes, and that her profound loss of peripheral vision in both eyes qualifies her as legally blind as of his examination date as well. Ms. Cleaver also suffers from cystoid macular edema, or CME, that is also noted in ophthalmology records of Dr. Kim from 2011. More recently in 2014 the ophthalmology clinic records from County Hospital identify a right conjunctival cyst. Dr. Simpson in addition to retinitis pigmentosa and CME, indicates additional diagnoses of vitreous degeneration, visual field deficits, epiretinal membrane of both eyes and posterior capsular opacity of the lens of the right eye. Various records document Ms. Cleaver’s ongoing and intensifying complaints to her medical providers about how her vision is limiting her ability to carry out simple daily activities. A “Verification of Need for Reasonable Accommodation” form for the Robbin Pennsylvania Housing Authority dated July 26, 2004 and signed by Ms. Cleaver and also by her physician indicates a request for a first floor housing unit because she “has degenerative joint disease and poor vision” and “has difficulty doing stairs”. In 2008 Ms. Cleaver applied for ADA Paratransit Services, the application for which indicates Ms. Cleaver’s vision/retinitis pigmentosa prevents her from using fixed-route bus services. More recently, the visit record from primary care physician, Dr. Stone, dated June 12, 2012 states, “She is having increasing difficulty getting around. Her vision is getting worse.” In the past Ms. Cleaver has not consistently complied with her primary care doctor’s recommendations to be routinely seen by an ophthalmologist, preferring to see an optometrist to revise her eyeglass lenses prescription as needed. As recently as October 2014 at a primary care provider appointment in Vermont the medical record indicates that Ms. Cleaver had not yet seen an ophthalmologist since moving to Vermont, though she had been previously referred and in February 2014 the ophthalmologist at County Hospital indicated she should attend a follow up appointment in six months. After repeated referral she did comply with attending an ophthalmology appointment. Lack of adequate vision has obvious consequences for functional independence and increases safety risks and failures in the past to seek care and treatment may or may not have impacted the severity of Ms. Cleaver’s symptoms. There are a vast array of services for the blind and also services specifically targeted to elderly persons who suffer from visual impairments and blindness. Particular service

June Cleaver

offerings vary by state, though there are also national organizations that provide chapter offerings in many states. When Ms. Cleaver lived in Pennsylvania, she would have been able to access services through the state’s Bureau of Blindness and Visual Services (BBVS), as well as through other public and private agencies. There is no evidence that Ms. Cleaver availed herself of these resources though the service offerings may have proven beneficial in addressing Ms. Cleaver’s documented complaints. For example, the Pennsylvania BBVS provides blindness skills training, mobility/travel instruction, and instruction on performing activities of daily living, and purchasing of assistive equipment. Additionally the BBVS offers advocacy, counseling, information and referral as service components of their independent living skills offerings. Since Ms. Cleaver moved and now resides in Vermont, she is able to access similar services through the Vermont Department of Rehabilitation Services, Bureau of Education and Services for the Blind (BESB), the Vermont State Department on Aging, as well as through other public and private agencies. Dr. Simpson indicates that Ms. Cleaver should obtain a formal activities of daily living assessment from the state agency for the visually impaired, which in Vermont would be the BESB. Indeed the BESB lists their service provisions as including assessment and instruction to improve activities of daily life, among other offerings. Arthritis/Polyarthralgia: The fact that Ms. Cleaver has progressive, painful arthritis in her back, shoulders, neck, arms, hands, and legs is an important consideration. Ms. Cleaver has suffered from degenerative joint disease for many years and has complained about pain symptoms affecting all major areas of her body. Her low back and neck pain have been the most persistent and repeated complaints resulting in physicians completing numerous medical workups including a multiplicity of x-rays and radiologic scans dating back more than ten years. At various times she has also complained about numbness and tingling symptoms accompanying pain, which has resulted in nerve conduction studies being completed. The results of x-rays, scans and related tests document progressive musculoskeletal problems that Ms. Cleaver has reported to providers as causing her a great deal of difficulties over the past at least two decades. For example, radiologic reports from August of 1994 indicate evidence of levoscoliosis (spine leaning to the left) in the midthoracic area as well as evidence of degenerative changes. In December 1994 imaging of the cervical spine also evidenced degenerative findings. A whole body bone scan completed on December 30, 1996 indicates findings that include thoracic scoliosis and secondary degenerative changes noted to be likely arthritic in nature. An x-ray report on the lumbar spine dated August 21, 1999 indicates findings of apparent degenerative changes at several levels. On March 13, 2000 a radiologic imaging report indicates that the cervical spine evidences “increase in the degenerative process” since the prior imaging study of December 1994, and a diagnoses of degenerative joint disease noted.

June Cleaver

At an office visit appointment on August 12, 1998, there is documented complaint of Ms. Cleaver having pain in her left knee and reporting that it “feels like it is giving out”. A diagnosis of degenerative joint disease in the left knee is listed. A report dated April 26, 2000 from Dr. Lisa Smith, M.D., who completed a physical examination of Ms. Cleaver, a review of her x-ray information, and completed an EMG study, indicates she was “complaining of numbness and tingling in her hands for some time” and that it was “getting to be more and more of a problem.” At an office visit appointment on May 2, 2000 Ms. Cleaver reported to her physician that she was told she had nerve damage in both hands and the physician ordered a follow up MRI examination of the cervical spine. In February 2002 Ms. Cleaver was in a car accident and suffered neck strain that resulted in x-rays being completed that evidenced degenerative changes. In 2004, as noted previously, Ms. Cleaver indicated her degenerative disc disease was a factor in making application to the local housing authority for a first floor unit. At a January 28, 2005 appointment Ms. Cleaver complained of a lot of pain in her neck and her chest. In June 2005 Ms. Cleaver complained of neck pain and was experiencing daily headaches along with numbness in her hands. In June 2006 Ms. Cleaver had MRI imaging of her lumbar spine completed that demonstrated lumbar levoscoliosis (leaning to the left), multi-level disc degeneration, and facet disease; as well as spinal stenosis. At a provider appointment in July 2006 chronic back pain is documented. In 2008 radiologic imaging of Ms. Cleaver’s cervical spine revealed severe degenerative disc disease and in comparison to an earlier 2005 study, the disease was found to be progressing. Additionally, the record of the Ester Arthritis and Osteoporosis Center dated October 28, 2010, indicates that “X-rays of the shoulders, cervical spine, lumbar spine, and hips demonstrate osteoarthritic changes.” Later cervical spine imaging completed in 2009, which was completed due to Ms. Cleaver’s intensified complaints of pain and numbness, revealed a herniated cervical disc along with the known degenerative disc disease. At this time Ms. Cleaver was offered pain management or surgical intervention and declined to follow the recommendation. In 2010 Ms. Cleaver had further complaints of pain in her left shoulder, in addition to complaints about back and neck pain. Her primary care doctor provided referral to a rheumatologist and that physician provided steroid injections to the shoulder to help relieve the pain. In 2011 Ms. Cleaver had a chest x-ray for purposes of diagnosing pneumonia, which also revealed degenerative changes in the spine. At a provider appointment in June 2012 degenerative disc disease is documented again, and on May 13th 2013 complaints of back pain are documented. Also in 2011, Ms. Cleaver’s primary care physician Dr. Stone wrote a letter dated October 24, pertaining to Ms. Cleaver’s conditions. The letter states that:

June Cleaver

“She is being followed for hypertension, hyperlipidemia, hypothyroidism, and retinitis pigmentosa. She also has multiple joint pains that have recently been evaluated by blood. Blood results indicate that there is a connective tissue disorder going on. She has a history of asthma, which has been getting progressively worse.”

Available pharmacy records further indicate that Ms. Cleaver has been taking various medications, including Tylenol with codeine, since at least 2005 to manage chronic pain. Greater detail on Ms. Cleaver’s prescription record follows in a later section of this document. Also the topics of pain medication, musculoskeletal problems, and reports of chronic pain are further addressed in greater detail in subsequent sections of this document as those issues correspond to the Billingsly Life Care Plan report. Headaches & Dizziness: Ms. Cleaver has a history of headaches and dizziness for which she has sought care and been prescribed medications since at least the 1990s. At a St. James Hospital provider appointment on November 19, 1993, for example Ms. Cleaver complained of feeling dizzy due to blood pressure medications. She additionally reported at that time that she had a history of migraines dating back five years. In November 1994 Ms. Cleaver is referred for an audiology examination due to history of vertigo. The provider record from Dr. Miller at the Ester Arthritis and Osteoporosis Clinic dated April 24, 2008 indicates under the heading of neurologic symptoms that Ms. Cleaver is positive for episodes of headaches and dizziness. The record also contains notation of positive for ringing in the ears. A medical history form completed by Ms. Cleaver for a urology appointment in October 2008 indicates that she “sometimes gets headaches and used to get them every day.” Coronary Artery Disease & Hypertension: Ms. Cleaver’s hypertension has been present since at least 2005 and her diagnosis of coronary artery disease is recorded in 2010. She receives prescription medication for blood pressure control and is monitored by her primary care physician at regular intervals for these conditions. Ms. Cleaver has reported chest pains during some of her historic primary care medical appointments. Having coronary artery disease and hypertension places Ms. Cleaver at increased risk for additional health problems. Chronic Obstructive Pulmonary Disease: Ms. Cleaver suffers from COPD (chronic obstructive pulmonary disease). This is a chronic, progressive disease that makes breathing difficult. Symptoms Ms. Cleaver has suffered include chronic cough, shortness of breath, and chronic bronchitis. Ms. Cleaver is historically a cigarette smoker for over 60 years, and smokers are more prone to the disease though it can be caused by factors other than smoking. Ms. Cleaver has been diagnosed with asthma, which is a subtype of COPD. July and September of 2004 two office visit appointments in which Ms. Cleaver was given prescriptions inhaler Advair for her difficulty breathing due to asthma and she continued

June Cleaver

to receive and fill such prescriptions in subsequent years. Ms. Cleaver has also required hospital care in the past for acute exacerbation of asthma. Additional Pre-Morbid Medical Conditions: Additional, though less pervasive and less severe, other conditions that Ms. Cleaver was diagnosed with prior to the time of the accident include but are not limited to: hypothyroidism, hyperlipidemia, diverticulitis; colon polyps; renal stones; renal cysts; urinary urge incontinence; carpal tunnel syndrome and history of anxiety and depression. Also, in 2006 an MRI scan of the brain indicated findings suggesting minimal chronic small vessel ischemia (lack of oxygen to the brain). Accident Related Injuries: Injuries attributable to the motor vehicle accident of October 14, 2013 are a scapula fracture of the right shoulder with involvement of the coracoid and glenoid, nasal bone fractures and segmental fractures of the right second, third, fourth, fifth and sixth ribs and a mildly displaced fracture of the seventh rib. The Robbins Hospital records contain and ophthalmology evaluation that indicates no accident related ocular injuries other than periorbital ecchymosis. Recent Rehabilitation Related Medical Treatments: Following the accident Ms. Cleaver received care in the acute medical hospital, Robbins Hospital, for approximately twelve days. She was discharged to County Rehabilitation Hospital where she received care for approximately eight days. Upon discharge from the rehabilitation hospital Ms. Cleaver was recommended to follow up with home health therapy services followed by outpatient therapy services. To date LCI has not received any record of home health services having been received after Ms. Cleaver left the rehabilitation hospital. The detailed trajectory of Ms. Cleaver rehabilitation related care is as follows:

- Robbins Hospital, Robbins PA; 10/21/13 through 11/02/13; discharged to County Hospital for inpatient rehabilitation

- County Rehabilitation Hospital, Brooklyn, NY; 11/02/13 through 11/08/13; discharged to home, went to live with daughter at that time in Brooklyn NY

- Outpatient physical and occupational therapy services at County Rehabilitation Hospital;

o PT started 12/26/13, plan of treatment for 2x weekly for two to three weeks, with six sessions attended through 01/16/14

o OT started 12/26/13, plan of treatment written for 2x weekly for four weeks, with six sessions attended through 01/16/14

- Orthopedic Clinic appointment on January 21, 2014 at County Hospital to follow up on fractures related to shoulder and nasal bones

- Fracture Clinic appointment on February 4, 2014 at County Hospital to follow up on shoulder fracture

June Cleaver

- ENT Clinic appointment on February 14, 2014 at County Hospital to follow up on nasal fractures

- Outpatient occupational therapy for right shoulder at Easter Seal of Central Vermont, plan of treatment written for eight sessions over four weeks beginning on 11/5/14; last session of this treatment plan attended 12/11/14, four sessions pertaining to this treatment plan were not attended

Additionally Ms. Cleaver has attended various primary care and specialist provider office visit appointments between January 2014 and January 2015 as per medical records, to follow up on the status of both her accident related and non-accident related medical conditions. Status of Accident Related Injuries: Records from the fracture clinic at County Hospital and the report of Dr. Dutton indicate that Ms. Cleaver scapular fractures and rib fractures have healed. Dr. Dutton indicates Ms. Cleaver has reached maximum medical improvement and that no further rehabilitation management is needed. In regards to the nasal fractures, plastic surgery was consulted following the accident and found that Ms. Cleaver was not a good surgical candidate and recommended that healing be managed non-operatively. On imaging a foreign body was seen in the nasal sinus, and this was later discussed at an ENT (ears nose and throat) clinic appointment at County Hospital, following completion of Ms. Cleaver course of inpatient and outpatient therapies, on February 14, 2014. At that time Ms. Cleaver indicated belief that a prior tooth extraction performed by a historic clinician may have displaced a tooth into the nasal sinus. Records from that appointment include the following:

“Asymptomatic tooth in nasal sinus, confirmation with facial x-ray. No surgical intervention.”

Ms. Cleaver was recommended to return to clinic if symptoms arise, and was recommended to use saline nasal spray twice daily. Later records of a primary care provider appointment on May 21, 2014 indicate that Ms. Cleaver suffers from allergic rhinitis, and Flonase nasal spray is prescribed for treatment. Medications: Available pharmacy records dated from May 2006 through early February 2014 indicate that among her historic medications, Ms. Cleaver has taken the following as pertain to for her various conditions: Medication

Type/ Purpose Years Prescribed

Generic Darvocet (propoxyphene-acetaminophen)

Narcotic, pain 2006; 2008

Generic Tylenol #3 (acetaminophen w/codeine

Narcotic, pain 2007; 2008; 2009; 2010; 2011; 2012; 2013

June Cleaver

Generic Percocet (oxycodone-acetaminophen)

Narcotic, pain 2011

Ibuprophen 600 mg & 800 mg prescription strength

NSAID, pain 2009; 2013

Indomethacin NSAID, pain arthritis 2011 Prednisone Steroid, anti-

inflammatory/ arthritis 2008; 2011

Meloxicam NSAID, pain 2012 Generic Flexeril (cyclobenzaprine)

Muscle relaxant 2007; 2014

Gabapentin Pain/ neuropathy 2014 Meclizine Dizziness 2012; 2013 Generic Ambien (zolpidem tartrate)

Sleep aid 2009; 2010; 2011; 2012

Generic Restoril (temazepam) Sleep aid 2008; 2012 Generic Valium (diazepam) Anti-anxiety/ Sleep aid 2009 Generic Ditropan (oxybutynin) Bladder control 2007 Diovan brand or Valsartan-HCTZ generic

Hypertension From 2007 every year through 2014

Levothyroxine Thyroid hormone/ Hypothyroidism

From 2006 every year through 2014

Combivent, Ventolin, or Spiriva inhaler

COPD/ Shortness of breath

2007; 2011; 2012; 2013

Generic Zoloft (sertraline) Antidepressant 2010; 2011 Generic Cymbalta (duloxetine) Antidepressant 2014 Billingsly Life Care Plan Review: Because the Billingsly Life Care Plan report lumps together all of Ms. Cleaver difficulties in stating her future needs and care costs, without separating what may be attributable specifically to the accident related injuries, an effort is undertaken here to analyze the various health issues itemized within the plan individually. This will further explicate the historic origins and chronic nature of the health factors contributing to Ms. Cleaver’s overall clinical condition as based upon facts in Ms. Cleaver’s medical record, and further differentiate what is related to Ms. Cleaver’s extensive clinical history from what is related to the accident. The Billingsly plan states that it addresses “chronic pain, ADL deficits, and impaired mobility” as secondary to the accident of October 14, 2013. This statement presents difficulty in light of the plan content because while Ms. Cleaver suffers “chronic pain, ADL deficits, and impaired mobility” now, she also suffered these same deficits prior to the accident. In fact Ms. Cleaver suffered these deficits for more than ten years and in some cases more than twenty years prior to the accident. The Billingsly plan, while acknowledging some components of Ms. Cleaver pre-existing conditions and problems, does not clearly explicate these premorbid, pre-accident problems and does not take these into consideration in the conclusory statements or in the cost projections.

June Cleaver

The narrative of the Billingsly plan itemizes twelve areas that are referred to under the labeled category of “rehabilitation assessment”. The plan then draws a number of conclusions under the category of “future implications” and concludes with cost projections. Content of each of these warrant discussion and exploration in light of Ms. Cleaver overall past and current clinical condition and well documented medical history. The twelve itemized areas as presented in the “rehabilitation assessment” section of the Billingsly plan contain overlapping information so that multiple life domains are discussed under each subheading. For example, information about pre-morbid functioning is interspersed within multiple subheadings, as is information about historic prescription medication usage. A combination of facts from the medical records along with anecdotal information that is inferred as having been received from Ms. Cleaver and/or her family is combined in such a way that discernment requires careful Robbins. LCI offers commentary on each of these twelve itemized areas with attention to factual data from Ms. Cleaver’s medical records: Billingsly #1-“Altered Health Maintenance” LCI Commentary: This portion of the Billingsly plan itemizes diagnoses, medical providers, medications prior to injury, medications after injury, equipment and health status. It infers that gabapentin and nasal spray were prescribed after the injury and also due to the injury. However, gabapentin is used to treat neuropathic pain, which is a condition Ms. Cleaver is documented as having suffered prior to the accident. Nasal spray is used to treat breathing difficulties, which Ms. Cleaver also suffered prior to the accident. In fact, at the ENT clinic appointment of February 2014 saline spray is recommended as related to a tooth lodged in the nasal sinus that Ms. Cleaver’s attributed to a prior dental clinicians’ prior tooth extraction work, and at a later primary care provider Flonase nasal spray is prescribed for allergic rhinitis This section of the report further states that Ms. Cleaver “refused” prior offer of surgery as related to nasal fractures, while the records indicate that she was deemed to be a poor surgical candidate and recommended for non-surgical management. Billingsly #2-“Impaired Physical Mobility/High Risk for Injury/Activity Intolerance” LCI Commentary: The Billingsly document states that prior to the injury Ms. Cleaver “was able to walk up to one or two hours” and “would run/walk for 15 to 20 minutes 3-4 times/week” when in fact there is no evidence of Ms. Cleaver running or engaging in this extent of physical activity. Such an activity level is highly improbable at any time in close proximity to the year of the accident, given Ms. Cleaver’s longstanding and intensifying complaints of pain since the 1990s. While it may be that Ms. Cleaver reported such activity to Ms. Billingsly, the claim lacks factual basis. As previously noted, Ms. Cleaver completed and signed a “Verification of Need for Reasonable Accommodation” form for the Robbins Pennsylvania Housing Authority dated July 26, 2004, that was also signed by her physician, indicating a request for a first floor housing unit because she “has degenerative joint disease and poor vision” and “has difficulty doing stairs”. Then in September 2008, she applied for ADA Paratransit

June Cleaver

services and in completing that application indicated “no” to the question asking if she could travel 200 feet without the assistance of another person, and indicated that she could climb three 12-inch steps “at times with assistance.” Documentation in the October 2008 medical record of Dr. Miller at the Ester Arthritis and Osteoporosis Center indicates Ms. Cleaver “does not exercise regularly.” The records consistently attribute Ms. Cleaver’s deteriorating vision, back pain, neck pain, and related pain symptoms such as numbness and tingling, as the causative factors for her mobility and activity difficulties. The Billingsly report proceeds in this section to list a large number of items that are classified under the subheading “after accident”. The items in the list are a collection of phrases that cover a variety of topics. Quotations are utilized and it is unclear if the quotes are from Ms. Cleaver’s verbal reports, from other persons’ verbal reports, or from annotations in the records. It is also unclear as to whether or not the items are based upon the home visit assessment and observations or are based upon Ms. Cleaver’s self-report. For example, the items listed as “Difficult to get into a car due to chronic pain” and “twitching in left leg and right arm with back pain” do not include any information as to what the basis is for such statements. These statements also omit any information about how such issues relate to long standing chronic and degenerative disease conditions. As such the statements lack basis for inclusion in this categorical subheading. For example, the items listed as “decreased walking tolerance”, “decreased endurance and balance”, and others that note the avoidance of stairs and presence of dizziness do not have relevance to the accident injuries per se, because Ms. Cleaver is clearly documented as experiencing these problems prior to the accident. In fact and as noted, Ms. Cleaver filled prescription medications for the drug meclizine, which is commonly used to treat dizziness, in June 2012, August 2012, and May 2013. There are a significant number of medical record notations from prior to the accident date that indicates Ms. Cleaver is having difficulty navigating her surroundings due to vision. For example, in the office visit note from primary care physician Dr. Stone for Ms. Cleaver’s August 15, 2013 appointment, approximately two months before the accident: “She complains of increased difficulty seeing. She has difficulty getting around.” The same office visit note goes on to document Ms. Cleaver’s complaints of further mobility and pain issues:

“She says her legs feel very heavy and sometimes she cannot get out of bed or cannot get out of a chair. The pain starts in her back and it radiates down both legs when they get numb. This is worse on the left than the right. She had looked into getting a home health aide for her, but her son lives with her so she would not qualify for right now.”

June Cleaver

Ms. Cleaver’s prescription medication history reveals longstanding and consistent use of pain medication consistent with the medical records that states such medicine was used for relief of severe arthritis pain. Several years before the accident, in 2010 for example, Ms. Cleaver filled a prescription for acetaminophen with codeine, or generic Tylenol #3, for 50 pills. In calendar year 2011 she filled generic Tylenol #3 prescriptions on four occasions; in January for 60 pills, in April for an unknown number of pills, in September for 60 pills, and also in November for 60 pills; she additionally filled prescriptions for generic Percocet and indomethacin, also pain relievers, in November 2011. In calendar year 2012, Ms. Cleaver filled generic Tylenol #3 prescriptions three times; in January for 60 pills, in February for 60 pills, and in April for 60 pills. Also in 2012, she filled prescriptions for a common gout medication, colcrys, in January and February. In September 2012 Ms. Cleaver filled a prescription for the anti-inflammatory medication meloxicam, which is also commonly prescribed for arthritis pain. In May 2013 Ms. Cleaver filled a prescription for generic Tylenol #3 for 50 pills, and in August of 2013 she filled a prescription for 800 mg strength Ibuprophen. Since the time of the accident, available pharmacy records indicate that Ms. Cleaver has filled one prescription for generic Tylenol #3 following her hospital discharge in November 2013. It is noted that at the time of her discharge from the rehabilitation hospital Ms. Cleaver’s was not prescribed any narcotic pain medication. More recently records indicate that Ms. Cleaver has asked her newer medical providers for additional narcotic pain prescriptions that they have refused to write, instead emphasizing the benefit of pain management with non-narcotic agents. Ms. Cleaver has filled subsequent prescriptions for gabapentin in at least April, May and June of 2014, after which time prescription records were not available. There is a notation however, in provider Sue Smith’s chart records indicating while Ms. Cleaver stated the gabapentin was providing some relief in May 2014, later during an appointment record in October 2014 the record indicates Ms. Cleaver stopped taking the gabapentin because it was not helping her. Further attention to pain-specific issues follow in a later section of this report that corresponds with the Billingsly report section of the same foci. The next subheading of the “Impaired Physical Mobility” section of the Billingsly report also lists a number of items under the category of “therapy issues”. The document does not recount Ms. Cleaver’s previous performance in therapy sessions and in terms of current therapy status merely states that she had been referred for hand therapy by Dr. Georgia, a statement that is believed to be in reference to the primary care provider and nurse practitioner Sue Smith, who in fact provided a referral for physical/ occupational therapy in March 2014 that Ms. Cleaver’s did not follow through with until November 2014, after she had been re-referred a second time. In examination of Ms. Cleaver’s medical records however, there is a great deal of information available that more specifically addresses Ms. Cleaver therapy issues than does the Billingsly document. It is noteworthy that while initially undergoing

June Cleaver

rehabilitation therapies following the accident, Ms. Cleaver had been recommended to have home health outpatient therapy put into place immediately following her November 8, 2013 discharge from County Hospital in New York; yet at her outpatient physical and occupational therapy sessions on December 26th, approximately seven weeks after leaving the hospital, Ms. Cleaver reported to the therapist that was her first post-hospital therapy session. If this is true, Dr. Dutton indicates that such delay in follow through with recommended treatment may have had adverse clinical effects on Ms. Cleaver recuperation. Again, this is an example of her lack of compliance with her medical providers’ treatment plan. The Billingsly report is dated July 10, 2014 and states Ms. Cleaver is not currently receiving therapy as of that date. An appointment record from primary care provider Sue Smith dated March 26, 2014 states, “I referred her to PT, she states she will start next week”. At a follow up appointment on May 21, 2014 the record states:

“She was referred to PT, did not go, not interested. She requested referral to pain management, which was done, now she states she doesn’t want to go. ‘I only want to come here.’ She continues to request Rx for Percocet.”

On October 27th, the last available record from provider Foley, it indicates similarly, “She was referred to ortho and PT but did not go.” During that October 27th appointment Ms. Cleaver was again recommended to pursue physical therapy, and in November 2014, Ms. Cleaver began outpatient occupational therapy services for her shoulder at the Easter Seals. According to the Easter Seals treatment plan, Ms. Cleaver was scheduled to receive eight sessions of occupational therapy over the course of two months, with two sessions per week starting with the first session on November 5, 2014. Records indicate that Ms. Cleaver attended the first four sessions, and then she is listed as “no show” for two of the remaining four sessions and “cancelled” for the other two of the remaining four. Her last appointment attended during this documented course of treatment was December 11, 2014. So instead of receiving therapy eight times over four weeks as recommended, available records indicate that Ms. Cleaver received only four sessions over four weeks. Ms. Cleaver is consistent with her lack of follow through and compliance with her treatment plan which is likely to have had a negative impact on her shoulder mobility and level of pain. The issues of mobility, function, and pain are also documented in provider records though they are not referenced in the rehabilitation assessment section of the Billingsly document. Ms. Cleaver’s medical records indicate that during examination by orthopedist Dr. Stanke at County Hospital in February 2014, months prior to completion of the Billingsly report, Ms. Cleaver was noted to have good range of motion in her right shoulder. Later, during a the primary care provider appointment of October 27, 2014 the primary care provider recorded that Ms. Cleaver was doing her activities of daily living on her own.

June Cleaver

While the Billingsly plan recommends ongoing therapeutic modalities for Ms. Cleaver, the benefit of ongoing compliance with the prior recommended home exercise program is not mentioned and issues of noncompliance are not addressed. Compliance with the treatment plan is a significant factor in this case since the complaints are centered on pain and mobility, and there is simultaneous noncompliance with programs of care that are designed to help to alleviate these symptoms. At this time, Dr. Dutton states that Ms. Cleaver has attained maximum medical improvement in her shoulder and that a home exercise program is the appropriate ongoing recommendation. Billingsly #3-“Potential for Alteration in Nutrition” LCI Commentary: A decreased appetite and occasional choking when swallowing are noted in this section of the Billingsly report and inferred as related to the accident; however this conclusion lacks basis. Ms. Cleaver height and weight have been documented at various intervals throughout her medical record. Her weight in 2008 and also in 2010 was recorded as 150 pounds. Her weight in October of 2014 was 162 pounds, with a corresponding body mass index *BMI) of 30.38, which places her in the Obese Class I classification category. Hypothyroidism can manifest various symptoms including weight gain, and Ms. Cleaver is noted in the records as reporting that her weight fluctuates some historically. Medications for hypothyroidism, which Ms. Cleaver is prescribed can help offset this symptom. Historically, Ms. Cleaver has a number of pre-existing gastrointestinal issues. For example, in 2008 she was diagnosed with colon polyps and also with renal stones and cysts; in 2009 she reported flank pain that the physician attributed to the renal cysts. In 2012 Ms. Cleaver was diagnosed with diverticulitis. At an office visit with primary care physician Dr. Stone on September 26, 2012, which was soon after hospitalization for abdominal pain and the resultant diverticulitis diagnoses, the doctor notes that Ms. Cleaver “has very little appetite.” Billingsly #4-“Chronic Pain” LCI Commentary: Ms. Cleaver medical history is significant for ongoing reports of pain in various body parts since at least 1998, with complaints intensifying and over time. Ms. Cleaver complaints pre-accident include: headache; neck pain; shoulder pain; back pain; arm pain; hand pain; leg pain; and foot pain. Complaints of pain are not intermittent but rather are reflected at the majority of medical appointments Ms. Cleaver attended over at least the past ten or more years. At times complaints of numbness in her legs, hands and/or arms accompany her complaints of pain. For example: In April of 2000 a physician visit record reflects complaint of “a lot of neck pain and pain in her arm”; in 2002 Ms. Cleaver was in a rear-ended car accident and records reflect damage to her neck and further neck pain; in January 2003 a record reflects complaint of “a lot of pain throughout all of her joints and as well as pain in her left ear”; in July 2004 an office visit complaint is listed as

June Cleaver

“She is complaining of a lot of back pain. She said it is very hard for her to get up in the morning and hard to get out of chairs.”

In September 2008 x-ray results indicated severe degenerative disc disease in Ms. Cleaver’s neck, worse than seen on prior x-rays. Later, on January 26, 2009 the physician reviewed an MRI of Ms. Cleaver cervical spine and offered pain management or surgical intervention for identified disc herniation, which Ms. Cleaver declined. Soon after on May 31, 2009 the doctor’s visit record includes the diagnoses of herniated cervical spine disc with radiculopathy, and also degenerative joint disease. An August 31, 2009 a doctor appointment record includes the notation “She feels achy all over in all of her joints…” and “She feels numbness in all of her extremities.” After that time Ms. Cleaver was referred to a rheumatologist and arthritis specialist to further diagnose and manage her pain issues. Dr. Sam Morris of the Arthritis and Osteoporosis Center examined Ms. Cleaver in October 2010, and on October 7, 2010 he reported the following in a letter to Dr. Stone, regarding Ms. Cleaver consultation appointment:

“She reports a chronic, over 5 year history of discomfort in both shoulders, as well as her neck, low back, and legs. The pain symptoms were typically on a daily basis and worse with rainy or cold weather. The pain tends to last all day, and it is worse with activity and improved with rest. The shoulder discomfort sometimes awakens her at nighttime.”

Even more recently, for example, the May 14, 2013 the doctor’s office visit note from Dr. Stone includes:

“She is complaining of a lot of numbness in both hands and it goes up the arm into the shoulder.” “She also complains of some thickening in her palm. When they are really gets swollen, she has difficulty making a fist.” “She has lower back pain and has some marked degenerative changes on previous test as well as some small herniations.”

These are excerpted examples that do not encompass the entirety of Ms. Cleaver pain complaints pre-accident. There are many additional references in the medical record to Ms. Cleaver complaints of pain as well as numerous x-rays, scans, examinations, and other medical tests that describe the debilitating and progressive nature of Ms. Cleaver progressing polyarthralgia. Given the debilitating and progressive nature of Ms. Cleaver musculoskeletal problems, it is not surprising that her complaints of chronic pain have persisted. Ms. Cleaver complaints of pain were consistently expressed throughout her pre-accident primary care provider appointments, as well as during specialist appointments. For example, a primary care appointment record of Dr. Stone dated March 11, 2008 states,

June Cleaver

“She continues to have joint pains. She also complains of feeling some pain at late night that seems somewhat restless.”

Later in 2008, on the history form for the Center for Urology dated October 13, Ms. Cleaver indicates that she has back pain and also writes on the form that she “sometimes gets headaches, and used to get them every day”. At an appointment on September 22, 2009 Dr. Stone documents that Ms. Cleaver has multiple joint pains. She includes in the diagnoses this day neuropathy, etiology unknown, and multiple joint pains with a positive rheumatoid factor. In a primary care appointment record dated May 24, 2010 Dr. Stone again writes “multiple joint pains” under diagnoses, and then in documenting an appointment on August 24, 2010 Dr. Stone writes “She continues to have the usual joint pains.” More recently, in 2014 after Ms. Cleaver had moved to Vermont post- accident, her new primary care provider Sue Smith records in the office visit record dated March 26, 2014:

“She describes her pain as being ‘deep down’. She cannot point to a location that hurts the most.”

At this appointment Ms. Cleaver is provided with prescriptions for Cymbalta and Flexeril. Later records indicate that she took the Cymbalta only once and stopped due to diarrhea, and stopped taking the Flexeril because she perceived no benefit. Also during this appointment a referral to was made to the Community Health Center (CHC) behavioral health (BH)/ mental health program. Later appointment records indicate that Ms. Cleaver never followed through with that referral. A primary care follow up visit note dated April 9, 2014 indicates that Ms. Cleaver continued to complain of pain and that she and her daughter, who was in attendance, ask for a referral to pain management that was provided. At the next follow up appointment on May 21st Ms. Cleaver continues to complain of pain. The record of this date states:

“She was referred to PT (physical therapy), did not go, not interested. She requested referral to pain management which was done, now she does not want to go. ‘I only want to come here.’ She continues to request rx for Percocet, ‘That is the only thing that helps me.’”

The Billingsly report indicates that “after accident” Ms. Cleaver has suffered daily headaches, yet there is no documentation of daily headaches in the medical records occurring post-accident. There is, however, a record of Ms. Cleaver suffering chronic headaches prior to the accident, and sometimes as often as daily. At a St. James Hospital provider appointment on November 19, 1993, as also previously noted, Ms. Cleaver reported a history of migraines dating back five years. Then in 2005 an ophthalmology record indicates Ms. Cleaver is to follow up with her primary care

June Cleaver

physician regarding “chronic headaches” and in 2008 Ms. Cleaver’s completes the form for the urologist that includes her report of prior daily headaches. The Billingsly report also indicates Ms. Cleaver reported use of Tylenol #3 to manage pain “once in a blue moon” pre-accident, whereas Ms. Cleaver’s pharmacy records delineate her filling such prescription four times in 2011, three times in 2012, and once in 2013 prior to her accident. Billingsly #5-“Potential for Impaired Skin Integrity” LCI Commentary: It is unclear why this is included in the Billingsly report as there is no subsequent data included other than “Skin intact at the time of evaluation.” Billingsly #6-“Altered Bowel Elimination- Bowel and Bladder” LCI Commentary: For bowel status the Billingsly report notes that Ms. Cleaver has episodes of diarrhea and constipation due to unknown cause. There is no basis for attributing this to the accident. For bladder status the Billingsly report notes that Ms. Cleaver experiences incontinence secondary to chronic pain. This is inconsistent with the medical records that depict Ms. Cleaver complaining of urinary incontinence as far back as 2005, when she expressed having urinary incontinence when coughing or laughing. Ms. Cleaver has had nine children and this is a relatively common genitourinary complication from childbirth especially multiple births. Ms. Cleaver previously received the bladder medication Ditropan in October of 2007 and in subsequent years it is documented that she asked her providers to prescribe a medication such as that once again to help with her bladder incontinence. Billingsly #7-“Self Care Deficit” LCI Commentary: While the Billingsly report notes Ms. Cleaver was “independent” in her function prior to the accident, records indicate that Ms. Cleaver was having increasing difficulties to the extent that she applied for home health aide services, as documented in the August 15, 2013 physician’s office note, which although previously noted in this document is restated here:

“She says her legs feel very heavy and sometimes she cannot get out of bed or cannot get out of a chair. The pain starts in her back and it radiates down both legs when they get numb. This is worse on the left than the right. She had looked into getting a home health aide for her, but her son lives with her so she would not qualify for right now.”

Prior to this doctor’s note in 2013 the following notation is in the medical record dated June 12, 2012:

"Her vision is getting worse. She has needed help going to the store. We may look into if there are any services available for her."

June Cleaver

Since Ms. Cleaver’s son and/or other family members are no longer formally living with her, she should be eligible for the same type of services that she previously sought, based upon the same diagnostic and self-care deficits that previously qualified her for such services. The Billingsly report in this section infers that Ms. Cleaver requires assistance with her activities of daily living (ADLs) and thus recommends attendant care both in this section and again in a later section of the document. The Billingsly report in both instances ignores the fact that Ms. Cleaver’s is documented in her medical record as being functionally independent in ADLs post-accident. Ms. Cleaver’s functional level, while not delineated by functional assessment within the Billingsly report, is well documented in the County Rehabilitation Hospital record and merits some review here: Upon Ms. Cleaver discharge from the inpatient program, the PT discharge summary states that her function is within normal limits. The OT discharge summary states that her left upper extremity is within normal limits, and her right upper extremity is within functional limits. Additionally, it is noted that documentation of the hospital physical therapy initial outpatient evaluation in December 2013 indicates that Ms. Cleaver was complaining of back pain and that Ms. Cleaver’s physical therapy goal was to ‘be pain free.’ During PT sessions Ms. Cleaver worked on increasing her strength and ability to walk distance. The physical therapist may or may not have been aware that Ms. Cleaver’s back pain was a long standing problem. Also in December 2013 the initial occupational therapy evaluation indicates Ms. Cleaver presented with pain and limited range of motion in her right shoulder. Ms. Cleaver’s personal/family OT goal is not noted; the occupational therapist’s long term goal is listed as Ms. Cleaver’s being able to use the affected upper extremity without complaint of discomfort. During OT sessions Ms. Cleaver worked on various short term goals including increased ability to do overhead activities. In both PT and OT domains, the primary problem impacting performance of ADLs and IALs was pain, and the focus of treatment modalities was pain reduction. Completion of ADLs per-se was not the identified problem being addressed, but rather completion of ADLs with diminished pain. In other words, Ms. Cleaver was not documented as having a deficit in completing her ADLs. Additionally and more recently, the records of primary care provider and nurse practitioner Sue Smith, in recording an office visit on October 27th, 2014 notes:

“She is now living by herself, her daughters/granddaughter come over to help her clean, but she does other ADLs on her own.”

This more recent record is thus consistent with the post-hospital therapy reports that Ms. Cleaver is functionally independent in her ADLs.

June Cleaver

Billingsly #8-“Home Maintenance Management-Impaired” LCI Commentary: This section recounts this history of Ms. Cleaver’s living arrangements. It does not specifically address Ms. Cleaver’s ability or inability to manage her home. The focal points the Billingsly report points out here include that Ms. Cleaver’s rationale for her move to the current living arrangement were twofold, to be near family and to live on the ground level, on one floor. These arrangements are pragmatic and practical for Ms. Cleaver given her visual status, chronic arthritis pain and other related historic health issues, independent of any issues related to the accident. Billingsly #9-“Sensory Perceptual Alteration/Impaired Thought Process” LCI Commentary: This section of the Billingsly document lists issues with vision, ringing in the ears, and sense of smell. There is no basis for attributing these issues to the accident. As noted, retinitis pigmentosa is a progressive eye disorder. Dr. Simpson indicates that any decline in visual function is due to the natural history of this disease. In regards to ringing in the ears, and as previously noted, Ms. Cleaver has endorsed this symptom previously to her medical providers, pre-accident. The medical record lacks overt evidence of impairment in Ms. Cleaver’s sense of smell, though her long standing problems related to COPD, asthma, and breathing are well documented. Billingsly #10-“Altered Sleep Pattern” LCI Commentary: Ms. Cleaver has complaints about sleep difficulty that are interspersed in the medical record with some regularity over many recent and past years. For example, at an appointment with her primary care physician on May 26, 2009, is it noted:

“She says she gets very anxious at night and then she just cannot sleep, but is afraid of taking anything too strong because of the diabetes.”

At this appointment the doctor prescribed Valium to be taken at bedtime and the prescription was filled June 3, 2009. One refill was provided which Ms. Cleaver obtained in July 2009. Following that time the doctor began prescribing generic Ambien, which Ms. Cleaver filled for several years as follows:

• 2009: September 25, quantity 30 • 2010: January 4 qu.30; January 27, qu. 90; April and August 28 for qu. 30 • 2011: January, March, June, July, August, September, October,

November, & December for quantity 30 each refill • 2012: February and April, for quantity 30 both refills

Then in September 2012 Ms. Cleaver filled a prescription for a generic form of the sleep aid Restoril. Medical records indicate Ms. Cleaver has historically attributed her sleep difficulties to both physical and emotional issues. For example, in August 2010 she reported that her son’s alcohol difficulties and her granddaughter moving out after

June Cleaver

having lived with her for nine years were causing her sleep issues. As previously noted, in October 2010 Dr. Morris recorded that Ms. Cleaver shoulder discomfort was causing sleep difficulties. Billingsly #11-“Individual Ineffective Coping/Self Esteem” LCI Commentary: This section of the Billingsly document describes Ms. Cleaver’s current living situation and how Ms. Cleaver self-imposes limits on her activities. Ms. Billingsly describes Ms. Cleaver as “home bound” though there is no medical reason why Ms. Cleaver should be home bound. Billingsly #12-“Caregiver Role Strain, Potential/Family Coping; Compromised/Family Process Altered” LCI Commentary: This section of the Billingsly report includes a list of a selected number of Ms. Cleaver family members and some information about her family history; it does not, as the title of the section implies, discuss caregiver role strain per-se. The Billingsly report recommends individual and family counseling and states the position that if family were not present, then placement in assisted living would be warranted. Ms. Cleaver has many documented personal, family and interpersonal issues that appear intermittently in her extensive medical record. There is however, no evidence in the record of Ms. Cleaver having had a mental health or behavioral health assessment. As such, counseling related issues have not been investigated and no treatment plan has been recommended. The primary care provider Sue Smith referred Ms. Cleaver for to the behavioral health/mental health provider at the Community Health Center in March 2014, but Ms. Cleaver did not follow through with that referral and a later appointment record dated May 21, 2014 states she refused to participate. In regards to assisted living, there is no basis for this recommendation as Ms. Cleaver’s is documented as independent in her activities of daily living. As previously noted in this report, Ms. Cleaver has progressive visual issues and her legally blind status likely qualifies her for services from the state agency for the visually impaired; Dr. Simpson has indicated she should seek out an assessment from this agency. Available services addressing instrumental activities such as shopping and safely navigating in the community are among the many blind service agency offerings designed to allow continued independent living. “Billingsly #12” is the final section of the Billingsly document that is contained under the broader “Rehabilitation Assessment” heading. The document proceeds from this point in describing future implications and then offering a plan with itemized costs, both of which are discussed in turn below. Billingsly’s “Future Implications”

June Cleaver

There are six itemized descriptors under this heading in the Billingsly report. The first statement draws the conclusion that Ms. Cleaver will need ongoing “comprehensive medical care and follow up” secondary to her injury. While it is true that Ms. Cleaver will undoubtedly benefit from comprehensive medical care and follow up to address her myriad issues, there is no basis for concluding that the injuries related to the accident are significantly pertinent to all of the care Ms. Cleaver should seek for the remainder of her lifetime. The major medical problems Ms. Cleaver faces are with regard to her retinitis pigmentosa and associated visual conditions, arthritis, hypertension, chronic obstructive pulmonary disease and the sequela of these conditions. These are the factors determining the vast majority of Ms. Cleaver’s future care needs. Dr. Dutton states that the only functional deficit Ms. Cleaver faces that is attributable to the accident is the decreased range of motion and strength of her right shoulder. This is primarily manifest in Ms. Cleaver increased difficulty and pain associated with overhead movements and/or with forward flexion. Dr. Dutton indicates that because Ms. Cleaver’s has achieved maximum medical improvement with regard to her shoulder, that there is no future rehabilitation intervention warranted other than home exercises to maintain as much range of motion as possible. The second statement within this section of the Billingsly report is that Ms. Cleaver will most likely require future emergency room visits and/or inpatient hospitalization secondary to her injury. While it is true that Ms. Cleaver may require future hospital care, there is no basis to conclude that such care would be due to the injuries sustained in the accident. Rather, Ms. Cleaver has a high potential for requiring hospital care as related to her chronic COPD, spinal issues, coronary artery disease, hypertension, and overall chronic disease burden. The shoulder is unlikely to cause a medical emergency that would require an emergency room visit and thus the statement has no basis in fact. The third statement in this section makes the claim that attendant care and case management is indicated. There is no basis for attributing the potential benefit of such services to the accident. In fact, and as the Billingsly report also acknowledges and as was noted in this document, Ms. Cleaver was actively seeking out home health aide services, which is another term for attendant care services, and reported that to her doctor in August 2013, approximately two months prior to the accident. At that time Ms. Cleaver’s son was living with her so she did not qualify for the services, which are presumed to have been through the State of Pennsylvania Department of Aging. Given that Ms. Cleaver felt the need for these services then, it is illogical to now attribute the need to issues resultant of the accident. The Billingsly document consistently ignores the pre-existing conditions that are present though these are the factors that would trigger the types of care the document recommends.

June Cleaver

Case management is also listed in this subsection of the Billingsly projections and also has no basis for attribution to the accident. If there were a primary benefit to case management for Ms. Cleaver, it would be coordination of care around her longstanding, multiple medical problems. Blind services agencies, such as Dr. Simpson recommended Ms. Cleaver seek assessment from, typically offer a case management component for qualified service recipients. The fourth statement in the Billingsly future care implications section regards Ms. Cleaver’s risk for injury and concludes that therapeutic evaluations and treatments, i.e. physical and occupational therapy, are indicated indefinitely. This is troublesome in several regards. First, the County treating therapists that provided outpatient services during Ms. Cleaver’s rehabilitation indicated that a home exercise program was the recommended follow up. Second, Ms. Cleaver has demonstrated noncompliance with attending therapy sessions, missing four out of eight that were scheduled as recently as November/December of 2014, and has stated to her primary care provider that she “does not like all these appointments”. Additionally, following the December 8, 2014 examination by Dr. Dutton he stated that Ms. Cleaver is stable and that it is unlikely that future therapy would provide any benefit. Dr. Dutton indicates that Ms. Cleaver has reached maximum medical improvement. The fifth statement in this section of the Billingsly report concludes that Ms. Cleaver will “continue to require assistance with all home maintenance and safety activities.” There is no basis to conclude that accident related issues constitute any significant cause of difficulties Ms. Cleaver may face with regard to home maintenance and safety. Instead, it is Ms. Cleaver’s increasing vision impairment that is the greatest compromiser of her safety, and her chronic back and neck pain and whole body arthritic symptoms that pose a major obstacle to home maintenance. The sixth and final statement in this section of the Billingsly report states the position that in absence of family support or in the instance of further functional decline or complications, an assisted living placement would be indicated. Again, the greatest risk factors for Ms. Cleaver’s condition deteriorating are those related to her longstanding chronic conditions and the burden this places on both her body systems and her overall functional capacities. There is no basis to project that the accident related injuries would be to the cause of any future placement needs. Additionally and as previously noted, there are blind services organizations that provide services intended to assist the visually impaired who wish to remain at home, as well as state agency on aging sponsored services with a similar focus, and the Billingsly report ignores these service options. Billingsly’s Cost Projections: There are eight categories of cost projections listed in Billingsly section VI. Overall there is no basis for concluding that Ms. Cleaver injury related issues are the trigger for any of the identified components of care. Furthermore, some of the care components represented in the cost projections are not appropriate for Ms. Cleaver, regardless of

June Cleaver

what rationale for potentially accessing them is considered. Some of the items not pertinent to Ms. Cleaver’s care needs serve no purpose but drive up costs. The following itemized observations are offered as means to further clarify these points: 1) Medical Services

a. Primary care is a medical necessity for Ms. Cleaver given her longstanding and chronic, progressive medical conditions; this is not attributable to the accident. The primary care that she has been accessing has been sufficient to meet her needs.

b. Specialty medical consults will be beneficial to Ms. Cleaver due to her overall clinical condition and myriad health problems, the majority of which are not attributable to accident. Pain management costs are required for overall pain management; however, it is not reasonable to presume that there is or would be any overall change to Ms. Cleaver’s physician directed pain management plan of care. Ms. Cleaver’s historically suffers from all-over body pain, and this has not changed.

2) Therapeutic Modalities a. Physical and occupational therapies have been pursued and participated in

by Ms. Cleaver as an outpatient on at least two documented occasions, both times with poor attendance; she has reached maximum medical improvement and further skilled services are not indicated.

b. Psychological counseling is a modality for which there is no indicated need. Ms. Cleaver’s prior long time physician prescribed medication as the treatment modality in addressing Ms. Cleaver prior, intermittent mental health symptoms. Although Ms. Cleaver was referred by her more recent primary care provider to the mental health/behavioral health department of the Community Health Practice, Ms. Cleaver refused to go. All mental health services begin and are dependent upon initial assessment; as Ms. Cleaver’s has not been assessed, there is no basis for attributing need for services, and no basis for concluding any specific etiology as pertains to any hypothetical need.

c. Therapeutic recreation consultation is not warranted as due to the accident; this recommendation/allocation lacks basis.

3) Supplies and Equipment a. Mobility; An electric scooter and an electric lift for a scooter are not warranted

and have not been recommended by any treating provider. An electric scooter is noted as counter-indicated for persons with severe visual impairment. A manual wheelchair and/or wheeled walker are also not warranted as costs attributable to accident related injuries. The outpatient physical therapist treating Ms. Cleaver as well as Dr. Dutton emphasize the benefit of Ms. Cleaver maintaining as much functional gait as possible. If

June Cleaver

mobility status and needs change this would be due to progressive effects of pre-existing chronic disease.

b. Activities of daily living aids; There are six components listed in this section: grab bars; hand held shower attachment; curved bath brush; toilet arm supports; reacher/grabber device and shower chair. Any need for such implements is not attributable to the accident. These devices serve to relieve stress and strain on the legs, back, neck, shoulders, arms and hands. Ms. Cleaver has pre-existing deficits and difficulties in all these body parts that supersede the time of the accident.

c. Medications; Ms. Cleaver’s prescription medication record provides factual evidence of her historic need for prescription pain medications and muscle relaxants, including narcotic preparations. Her medical record also contains notations about her use of over-the-counter medications to address her pain and other body maladies. Her ongoing need for such medications to manage her whole body pain and chronic disease issues has not changed. There is no basis for attributing or allocating any future costs to the accident. .

4) Laboratory studies; there is no basis for allocating future diagnostic cost to the accident. Ms. Cleaver is stable and has attained maximum medical improvement, and Dr. Dutton indicates there is no likely need for future diagnostic testing as related to Ms. Cleaver’s shoulder.

5) Medical/Rehabilitation management; There is no basis for this allocation as applicable to the accident related injuries. If the right shoulder should require medical attention Dr. Dutton indicates any needs can reasonable be attended to on an outpatient basis. The Billingsly report includes pain management as a subtopic of this item. As noted, Ms. Cleaver has complained of all-over body pain and been treated for whole body pain historically and the level of care as relates to this need will not change.

6) Personal care attendant and case management (listed as “Nursing services”); a. Personal care attendant; There is no basis for this allocation as primarily or

majority applicable to the accident related injuries. As documented, Ms. Cleaver was actively seeking personal attendant/home health aide services prior to the accident and the only known reason barring her from obtaining them was the fact that her son was living with her. The only functional change in Ms. Cleaver’s status attributable to the accident related injuries is her ability to use her right arm in active elevation above her head. Dr. Dutton indicates that while Ms. Cleaver may need assistance with getting dressed, bathing and cleaning, any need for home care would be more likely related to her musculoskeletal conditions and aging than to her limited shoulder function. The Billingsly plan also projects for a live-in attendant, which is excessive given Ms. Cleaver’s functional status and such projection serves to

June Cleaver

drive up cost. Intermittent, come and go services are more appropriately projected as the means to meet needs, though such needs would be present whether or not an accident had occurred.

b. Case management; There is no basis for this allocation based upon accident related injuries; the pertinent injuries are not of sufficient magnitude or complexity to warrant case management. Ms. Cleaver would benefit from case management for her overall clinical condition, and such services are available through aging and blind services organizations.

c. Assisted living residential placement in the absence of family support; there is no basis for this allocation based upon accident related injuries; the pertinent injuries do not significantly impact Ms. Cleaver’s status or needs to the extent those would warrant such placement. It is also noted that the assisted living prices also do not make sense when considering the very large cost difference between providers. It is unclear if the providers presented are truly offering the same service.

7) Home modifications; accessible bathroom/safety/ramping; there is no basis for this allocation based upon accident related injuries; the pertinent injuries are not of the type or magnitude and do not significantly impact Ms. Cleaver’s status or needs in a way that would trigger these needs. Additionally, Ms. Cleaver has lived and currently lives in rental housing and allocating $40,000 to modify a rental unit would not be feasible even in the event that modifications were appropriate to her needs.

8) Security; lifeline system and installation charge; There is no basis for this allocation based upon accident related injuries. It is noted that Ms. Cleaver may qualify for this at no-cost based on her blindness, with application made through the appropriate agency.

Summary & Recommendations: Ms. Cleaver will benefit from care and services to address her longstanding and progressive health problems. The accident of October 14, 2013 caused health problems from which Ms. Cleaver has recuperated and attained maximum medical improvement. She demonstrates limits in mobility in her right shoulder though medical records indicate that she remains able to complete her activities of daily living independently. Her overall plan of care and identified level of care need has not changed resultant of the accident. Any future care projections for medical and/or personal care as itemized in the Billingsly Life Care Plan report reflect components of care that would have been manifest overall based upon the clinical trajectory of Ms. Cleaver’s pre-existing, progressive, and chronic health conditions. While current and future care should take into account Ms. Cleaver accident related injuries, the type of care that is required has not changed to any significant extent.

June Cleaver

Given Ms. Cleaver’s previous, current and future status as an elderly and legally blind person, it would be to her advantage to avail herself of the wide variety of benefits and services available to her based on those criteria. Many services are available at no cost. In addition to the state agency, there are additional community based, privately funded blind service organizations that Ms. Cleaver would potentially benefit from accessing. These may provide additional sources of practical supports, services, and opportunities for social engagement. Ms. Cleaver may be qualified for additional vision supportive services such as acquisition of a guide-dog or assistance with transportation or chores provided by volunteers. Ms. Cleaver will also require ongoing follow up for her chronic medical conditions as itemized previously in this report. To that effect, she will benefit from maintaining close contact with a primary care physician who can act to coordinate and oversee her holistic care. Maintaining specialist medical appointments such as her primary care provider recommends addressing ophthalmic, arthritic, renal, gastrointestinal, endocrinological and mental health needs will also be of significant benefit for Ms. Cleaver. Following specialty provider recommendations for treatment modalities to palliate pain symptoms and, as best as possible to control symptoms of chronic disease, will aide in maximizing Ms. Cleaver’s quality of life.