international life care planning

Transcription

INTERNATIONAL LIFE CARE PLANNING:
TECHNIQUES, STRATEGIES AND DATABASES
KEITH SOFKA, ATP (RETIRED)
PENELOPE CARAGONNE, PH.D., CLCP
CARAGONNE AND ASSOCIATES, LLC
AJIJIC, JALISCO, MX
DEVELOPED FOR
THE AMERICAN BOARD OF VOCATIONAL EXPERTS (ABVE)
ANNUAL FORENSIC CONFERENCE
MEDICAL ASPECTS OF DISABILITY
MARCH 25 - 27, 2011
ORLANDO, FLORIDA
1.
A Basic Template for Conducting Research in Another Country
a.
Basic referral receipt.
b.
Get copy of plan if you’re on the defense, and/or all medical records.
c.
What is your role in the case? Are you a testifying expert, a non-testifying
consultant to the LCPlanner, or a non-testifying expert consultant to the
attorney at trial?
d.
Will you be working directly with the attorney or through a life care
planner? Your retention contract should be with the attorney, your primary
communications should be with the attorney, unless you absolutely trust
the life care planner and can do a contract with them. Distinguish between
small and large scopes of work.
e.
Will they need a testifying expert from another country? In health system?
In service delivery? In economics? In medicine?
f.
Can you speak or negotiate in the language? If yes, go for it. If no, get a
guide.
g.
Stay in every other day contact with your client and/or get him or her to
designate a person in his/her office to be your point person for information
and approval.
h.
To find a guide, make contacts with major hospitals to locate bi-lingual
physicians (Google search with Babelfish so you can translate the pages
you find). Find a physician or hospital director who is conversant with and
can use email.
i.
Make contacts with the Consulate and if they won’t help, ask for a list of
physicians or ask for a list of translators.
j.
Tell your client you may need to ire a consultant and/or translator and that
you will pay their bill and pass it on to them.
k.
Hire either a translator or negotiate with a physician for assistance.
l.
Offer to pay your consultants per hour once you have determined how
much you should pay for a physician/consultant (beware of the gringo tax).
m.
Develop a short written description of the person, or, a medical resume of
their injury and needs in the language of the country to send to your
consultant.
n.
Translate the list of items in the Care Plan to the language of the country.
o.
Once you have negotiated for a product, send the consultant your list of
everything that needs to be priced.
p.
Make an arrangement that you will pay for only the complete delivered list
of prices by a date certain.
q.
Make sure you have lengthy deadlines as other cultures do not work on
US time frames. If, for example, you get a pricing request with a 2 day
turn-around (as we just did), decline it.
r.
Do a site visit with a physician or nurse if you can (it’s always better).
s.
Explain to your client that if you are a testifying expert, you will have much
more credibility if you have visited the setting and can speak from direct
contact.
t.
Ask your consultant to take you to all the resources so you can see them
for yourself.
u.
Photograph every place you go.
v.
w.
x.
y.
z.
aa.
bb.
When you’re with vendors, get their emails, ask for written quotes, and
determine if the item can be shipped in and is available.
If not available, what would the Customs duty be to ship any item in (25%
up charge?).
Are there repair resources for the item to be shipped, and if not, consider
buying two of the item, so they can send one to a major metropolitan area
for repair and still have one working item.
Remember that the availability of online information is unique to the US
and western Europe.
Collect all of your data in a comparable format and enter it incrementally.
Scan and save your data files in PDF so you backup each page of your
Cost Charts with your foundational information (See Mexico City plan for a
guide).
Take this entire file to your deposition so if questions are raised, you can
refer the opposing attorney directly to your file.
2.
A Basic Template for Presenting Your Findings (US and "X" Country Cost
Comparisons in One Chart) (3 Life Care Plans)
3.
Working with Economists and How to Present Your Cost Information to
Them
a.
Be sure to alert the Economist regarding the most current dates of your
data. Do not assume that they will read or even look at anything but your
summary sheet.
b.
Interview the economist on what he is expected to do and when
c.
Tell the economist that you give comparative converted figures (US Cost
compared to “x” country costs, and the conversion rate)
d.
Ask them if they need CPI figures.
e.
Ask them if they need inflation rates.
f.
Ask them if they will need wage data.
g.
Ask the attorney if you can communicate directly with the economist, and
if they want you to do it all by telephone, so he continues to appear to be
an expert economist.
h.
Confirm by email or by telephone with the attorney what you will be doing
additional to the LCP research.
i.
When you finish your cost research, send one file to the attorney and one
to the economist.
j.
Obtain the economist’s final version of your numbers, so you can confirm
they understood the translation you sent.
4.
Attorney Perspectives on "Primitive" Local Medical Services (How to
Validate or Invalidate This Perspective)
a.
Find out fixed your attorney’s ideas are about the culture and his/her level
of cultural awareness
b.
If his level of awareness is low, tell him you will provide him with a lot of
pictures of the region, the home, and various vendors you will recommend
for his use during depositions
c.
Learn if they have a consultant/expert in immigration law
d.
e.
f.
g.
If, as in one case, the opposing attorney is asserting primitive conditions
for services, ask what proof the opposing attorney is offering so you can
review it (Typically, plaintiff attorneys opine that the person will never go
back to “x” country, as the services are far superior in the US).
If the person resides in a fairly sophisticated town or city, offer to do a site
visit so you can counter this argument with photos of your own and help
him/her get photographic familiarity with the region and its services
If, however, the place where the person is primitive (as many are)
document where the resources are and provide funds in your plan to travel
to these resources, or, put a physician led-team together to do on-site
services in the home and train the nursing staff
Example from North Carolina case where the case manager only provided
resources for three months per year of supplies and no physician followup
5.
Cultural Considerations
a.
The kind of directness that we are accustomed to in the United States may
be viewed as aggressive or even rude in other cultures. Instead of
suggesting an idea, which will almost always be met with assent, it is
usually more productive to ask what this person would do in a similar
situation. For more information about this topic, see the book: Crouch, N.
(2004). Mexicans and Americans: Cracking the Cultural Code. London:
Nicholas Brealey Publishing.
6.
Surgeon Availability for Inpatient and Surgical Pricing
a.
Get a surgeon for pricing as soon as you can
b.
Do not rely on estimates of prices provided by non-surgeons.
c.
In some countries, Peru for example, it will not be possible to get surgical
pricing, unless you know a physician personally.
d.
There are no databases in foreign countries that are comparable to our
US databases.
e.
If possible, put your request for a procedure in writing.
7.
Why You Should Avoid Medical Tourism Sources
a.
While the availability of medical tourism in a particular country may be a
testament to the quality of the medical infrastructure, many procedures are
not offered by these companies. If your required procedure is not on the
list of typically offered procedures, you may never get a cost since you will
be setting off a chain of price investigating events so that a price for all
potential patients will be sought by the Medical Tourism Company. You
will find that the most common procedures are available such as knee and
hip replacements while a scar revision will require lengthy price
investigation. It would be better to find a physician who performs this
procedure through the methods outlined above. Also, the prices charged
by medical tourism operators often include all of the extras not required by
a resident such as housing, transportation, etc. Generally, the price will be
higher for the procedure although it will still be much less expensive than
the same procedure performed in the United States–see Gringo tax.
8.
Paginas Amarillas (Yellow Pages for a Given Country) and Seccion Amarilla
(How to Use the Internet)
a.
Sección Amarilla (http://www.seccionamarilla.com)
b.
Paginas Amarillo (http://www.paginasamarillas.com)
9.
Locating Specialist Physician and other Provider Databases
a.
Major Hospitals
b.
Labs and Clinics
c.
Durable Medical Vendors
d.
Farmacias
e.
Adaptive Transportation
f.
Consejo De Doctores by Discipline.
http://www.consejorehabilitacion.org.mx/
g.
Procuraduría Federal del Consumidor (Profeco includes National Cost
Database and the Department of Transparency)
(http://www.profeco.gob.mx/)
h.
IMSS (Department of Transparency)
http://www.imss.gob.mx/transparencia
i.
Defining the Procedure. The ICD-9 in Spanish.
http://www.worldlingo.com/ma/enwiki/es/ICD-9-CM_Volume_3
The ICD-9 is available in many languages from this same site.
10.
Life Expectancy Tables
a.
World Health Organization, Global Health Observatory. Life Expectancy
for 193 member nations.
http://www.who.int/healthinfo/statistics/mortality_life_tables/en/
11.
The Value of Site Visits (Resource Proximity, Resource Staffing, Services
Offered, etc).
Plaintiff Cases
a.
What you can learn from a site visit (Carmelo)
b.
Characteristics of the family’s needs for support
c.
Capability of the family to directly care for their family member
d.
Desire of the family for paid help
e.
Family needs for respite
f.
How patriarchal the family system is
g.
Family needs for architectural access or construction
h.
Family needs for help in managing resources
i.
Local resources for supplies, equipment, physician care, medications, and
nursing
j.
Desire for local resources to enter into contractual agreements with
insurance company
k.
Arrangements for getting bills from local vendors and physicians
l.
Arrangements for paying bills
Defense Cases
a.
Gain a better understanding of the resource network
b.
Sense of how wealthy or how poor the family is
c.
Proximity of resources to the family
d.
e.
Sophistication of resource network
Greater detail for setting up a resource network
12.
Health Insurance/Pension System (Original Constitutional Mandate , Recent
Amendments, Critiques of the System by Economists, Key Provisions, Types of
Worker Hospitals, Exclusions, What is Covered and Not Covered, Costs Per
Year in Mexico, Entering the System After a Catastrophic Injury, Translation
Resources for the Mexican IMSS document
a.
The Value of a Translated Health Insurance Document for Your Client
b.
Determining if the System will accept a catastrophically injured new
enrollee
c.
When injured workers can enter as an already enrolled family member’s
dependent
d.
Re-opening an old insurance account
e.
Two year rule
f.
Obtaining translated copies of the Mexican Health Care System.
MEXICANLAWS S.A. de C.V. <[email protected]>
13.
Commissioning a Report by In-Country Attorneys for Admission Into a US
Court
a.
Why you would do it
b.
Why you would not need to do it
14.
Giving a Deposition in Another Country (Use of Your Local Consulate as a
"Little Piece of America")
a.
Paying for use of their space
b.
Getting sworn in by a consulate representative
c.
Making arrangements for video or court-reporter services in advance
15.
Labor Market Databases (World-wide)
a.
The International Labour Organization
http://www.ilo.org/global/lang--en/index.htm
b.
Is in English, Spanish and French
c.
Contains data from most of the countries in the world (193 UN countries)
16.
Consumer Price Index Databases and How to Get (World-wide)
a.
Banco de Mexico. http://www.banxico.org.mx/index.html
b.
This information is kept by the central bank in each country. You can find
this by “googling” central bank, Bosnia, for example.
c.
Each central bank is required to keep this data
d.
Type in the term “Consumer Price Index” in the native language of that
country
e.
Less detailed information about each country’s CPI can be found at the
International Monetary Fund website. http://www.imf.org/ search for
statistical appendix and the name of the country.
17.
Setting Up Resource Networks with Insurance Companies or Other
Funding Sources (World-wide)
a.
b.
c.
d.
e.
f.
g.
18.
Determine how they will pay bills
Send the names and all relevant information on each of the local vendors
to the insurance company
Get approval in writing that they agree to pay
Get a contact person to whom bills will be sent
Get their email address so the vendor can send bills to you
Get their bank wiring information so they can wire money
Send a bill and see if they pay it
Key Provisions of a Translated Document (Certified Translator, Original
Document, Payment Structure)
#2
LONG-TERM CASE MANAGEMENT PLAN
FOR
SENOR CARMELO
MEXICO
PREPARED FOR
MR. FRANK
ATTORNEY AT LAW
THE LAW FIRM OF
AND
NORTH CAROLINA
BY
PENELOPE CARAGONNE, PH.D.
CARAGONNE AND ASSOCIATES, LLC
81 HIDALGO
AJIJIC, JALISCO, MEXICO
JUNE 23, 2003
LONG-TERM CASE MANAGEMENT PLAN
SENOR CARMELO
TABLE OF CONTENTS
I
REFERRAL FOR LONG-TERM PLANNING
REQUEST FOR LONG-TERM PLANNING
WORK PRODUCT REQUESTED
DEPARTURES FROM LIFE-CARE PLANNING WORK PRODUCTS
OMISSION OF COST INFORMATION
ENHANCED ELABORATION OF SERVICE
RECOMMENDATIONS
FORMATS USED IN PUBLIC SECTOR REPORTS
INCLUSION OF PHOTOGRAPHS IN THE PLAN
RECOMMENDATIONS FOR A SERVICE STRUCTURE THAT
CAN ENSURE SERVICE CONTINUITY AND
ACCOUNTABILITY
II
CURRENT MEXICAN CONTEXT AND SUMMARY OF WORKRELATED INJURY
SUMMARY OF MEXICO ECONOMY AND CIRCUMSTANCES
THE
AND
ENVIRONS
BACKGROUND HISTORY
EMPLOYMENT HISTORY
CIRCUMSTANCES OF WORK INJURY
01
06
III
POST-INJURY MEDICAL AND SERVICE HISTORY
14
MEDICAL SERVICES RECEIVED AFTER INJURY
UNIVERSITY OF NORTH CAROLINA HOSPITALS,
CHAPEL HILL, NC
SERVICE PROVIDERS AND THEIR INVOLVEMENT WITH CARMELO 18
SINCE RETURN TO MEXICO
TEXAS INSTITUTE FOR REHABILITATION AND RESEARCH,
21
HOUSTON, TX
CURRENT STATUS OF GOODS, SERVICES, AND PROJECTED
CASE MANAGEMENT CONTACTS FOR THE
FAMILY
IV
METHODS USED TO INVESTIGATE LONG-TERM NEEDS
RECORDS AND TEXT REVIEW
INTERDISCIPLINARY PLANNING
CONSULTATION WITH LUIS
MD
CONSULTATION WITH LOCAL SUPPLIERS
CONSULTATION WITH
26
MD,
CONSULTATION WITH KEITH SOFKA,
REHABILITATION ENGINEER
PLANNING EFFORTS WITH PORFIRIO
V
SUMMARY OF CURRENT CIRCUMSTANCES AND CONCLUSIONS DRAWN
AFTER HOME VISIT, RECORD REVIEW, AND CONSULTATION WITH
TREATING PHYSICIANS
THE
EJIJIDO
RISK FACTORS FOR SENOR
OVERALL PLAN OBJECTIVES OF SAFETY, HEALTH, AND
CONTINUED LIFE
APPROPRIATE HOUSING AND MODERN MEANS OF
COMMUNICATION
ACCESSIBILITY OF ADAPTED TRANSPORTATION
AVAILABILITY OF MEDICAL SERVICES
ADEQUACY OF FAMILY SUPPORTS
APPROPRIATENESS AND SUFFICIENCY OF SUPPLIES,
PRESCRIPTION MEDICATIONS, LABORATORY TESTS
AND DIAGNOSTIC WORKUPS
UTILITY OF CURRENT DURABLE MEDICAL GOODS
CONTINUITY OF CASE MANAGEMENT SUPPORTS
31
VI
RECOMMENDATIONS FOR FUTURE SERVICES
40
VII
RECOMMENDED REQUIREMENTS FOR LEGAL OVERSIGHT
A WORKABLE MODEL OF CASE MANAGEMENT FUNCTION
CHARACTERISTICS OF AN IMPLEMENTATION STRUCTURE THAT
ENSURES SERVICE ACCOUNTABILITY
56
APPENDICES
RANCHO LOS AMIGOS SCALE OF BRAIN INJURY FUNCTIONING
SECTION ONE
SENOR CARMELO
PLAN FOR LONG-TERM SERVICES
REFERRAL FOR PLAN DEVELOPMENT
REQUEST FOR LONG-TERM PLANNING Mr.
J.
of the law
firm of
and
North Carolina, contacted Caragonne and
Associates, LLC, in Guadalajara, MX in February 2003. Mr.
requested that
Caragonne and Associates research and develop a comprehensive and long-term
plan for Senor Carmelo
now residing in
San Luis Potosi
State, Mexico. Mr.
related that Mr.
was catastrophically injured
while at work in the United States and was returned to Mexico in a persistent
vegetative state, from which he would not recover. He is now cared for family
members. Mr.
explained that
was a small village in eastern
Mexico, located three hours from the larger Mexican metropolitan area of San Luis
Potosi, MX.
WORK PRODUCT REQUESTED Mr.
requested that Caragonne and
Associates complete an investigation of Senor
circumstances to develop a
comprehensive plan that would identify:
•
•
•
•
•
•
•
All interventions and services he requires
Services available and services prescribed but not provided
Problems with how services are currently identified and secured
Proper strategies for locating, securing, and retaining services
Suitable systems for vendor reimbursement
Methods for assessing service timeliness, receipt, and benefit
Characteristics of legal and procedural safe-guards
Mr.
clarified that the long-term care plan for Mr.
would be submitted
to the North Carolina Industrial Commission for approval. This factor influenced the
format and content of the completed plan in five ways.
Senor Carmelo
Plan for Long-Term Services
Caragonne and Associates, LLC
Guadalajara, Jalisco, MX
Page 1
DEPARTURES FROM LIFE CARE PLANNING WORK PRODUCTS
A.
Omission of Cost Information Detailed information on service cost
always accompanies development of Life Care Plans used in litigation contexts.
The cost information is portrayed in charts typically sub-divided by resource
category, i.e. medical services, prescriptions, adaptive equipment, transportation,
case management, etc. Within each resource category, individual rows identify
each resource by its purpose, representative vendor, date of initiation of the
resource, date of cessation of the resource, the replacement cycle for the resource,
its unit cost, average annual cost, and, in a separate column, costs for resources
purchased one-time only or costs if purchased on a time-limited basis. A Summary
Cost Chart may also be prepared summing all costs within each category. For the
following reason, cost information will not be part of the completed plan for Senor
Under North Carolina Workers' Compensation law, the Industrial
Commission will approve or modify the fees and costs of
medical items as such bills are submitted to the Industrial
Commission. Thus, Costs for Services will not be included in the
plan. It is this planner’s understanding that the Industrial
Commission will not award a dollar amount, but rather will
determine what medical care is deemed appropriate, not
requiring development of Cost Charts at this time.
B.
Enhanced Elaboration of Service Recommendations In most Life Care
Plans developed for litigation, a narrative is developed describing the injury, its sideeffects, services received, and services needed but not available. This narrative is
coupled with the Cost Charts. Reliance on use of this format is wide-spread, but
problematic. Unlike long-term plans developed for public sector use, planners in
litigation-based contexts are taught to omit descriptions of the methods they used
and the data they collected that forms the basis for their opinions. Typically, five
types of information are de-emphasized:
•
•
•
•
•
the geographic or living conditions for the consumer
their proximity to services needed
how the consumer is connected to these services, and,
what barriers–cultural, familial, financial or attitudinal–must be
overcome for service delivery to occur
how greater resource availability will materially change the
consumer’s circumstances
Senor Carmelo
Page 2
Few litigation-based life care planners document their desired end-result for a
consumer, e.g. greater accountability to the consumer on the part of providers,
reduction of depressive incidents, more rapid resource acquisition, fewer
unexplained interruptions in service, reduced care giver turnover, reduced inpatient
hospital days, fewer annual instances of pneumonia, weight stability, increased
use of adaptive equipment, reduction of contractures, reduction of health problems
for care givers, increased frequency of community access for the consumer–in
short, how the consumer’s circumstances will substantively change with greater
access to resources. This content is missing in much of the advanced training
offered to life care planners. While planners are taught how to identify specific
resources needed by individuals with disabilities, they aren’t provided with content
on how to anticipate and plan for the kinds of problems disabled consumers will
face as they seek services; why they fail to connect to services they need, and,
strategies that can overcome obstacles to service delivery.
In the past 40 years, significant levels of federal funding in mental health,
developmental disabilities, gerontology, and child welfare have been allocated to
examining these problems and evaluating the models of service that overcome
them. Federal funding has supported countless “cross-cutting” studies comparing
different models of service delivery to disabled consumers. Multiple studies have
generated useful information on advantageous ways to link consumers with the
services they need on a continuous basis. This research content is absent from
content now taught to life care planners.
Despite this wealth of information, planners operating out of a litigation context
omit descriptions of service approaches that can change the way the consumers
and service providers are linked together. Because how a consumer is–or is
not–linked to needed services remains outside the scope of most planners’ efforts,
these plans will lack coherence. Large scale medical, nursing, supply, housing,
and transportation systems often operate at cross-purposes with consumers
needs--to the detriment of the consumer. Senor
is uniquely vulnerable in
his dependence, health status, geographic isolation, and his family’s lack of
familiarity with why certain services are needed for his health and safety. His
family members are at a distinct disadvantage when advocating with large-scale
medical systems on an on-going basis. Recommendations made for Senor
therefore, will focus not only on the services he needs to obtain to
sustain life, but on the supports he needs to gain access to these services on a
more continuous basis than has been the case to date.
Senor Carmelo
Page 3
C. Format Used In Public Sector Reports This report makes a departure from
the “life care plan” format identified with litigation-based contexts and will apply a
report format practiced extensively in public sector agencies using a specific model
of face-to-face intensive case management services. In agencies serving
individuals at high risk for institutional placement, these agencies, e.g. mental
health, elderly, multi-problem family settings, child welfare, and developmental
disabilities settings, a case manager is required to appraise all life areas, e.g.
shelter, food, transportation, define the status of each, identify any problems
observed in each area, and make recommendations for resources that will offset
all deficits identified. Their reports evaluate not only the consumer’s immediate
physical needs but are also required to document identifiable problems with the
service delivery system that surrounds him and affects his ability to obtain
services. Plans prepared in agencies using this approach include direct
intervention with the person and direct intervention with the network of services
used by the person.
This report will follow that convention. Section One has described the referral
made for services and how this plan proposes to differ from typical litigation-based
“life care plans.” Section Two will next describe the circumstances of Sr.
injury. Section Three will summarize the scope and extent of interventions
completed for Senor
after his return to Mexico. Section Four will describe
steps taken to develop the long-term plan for Senor
methods used to
collect information and what information was collected to provide a foundation for
recommendations made. Section Five provides an analysis of conclusions drawn
after the home visit, records reviewed, consultations with treating providers. Risk
factors for Senor
are addressed, and overall plan objectives are reviewed.
relevant aspects of Senor
current circumstances, barriers to service, and
characteristics of a model case management that can overcome the problems
identified is advanced. This section analyzes the prevailing service conditions and
circumstances that affect Senor
as follows:
•
•
•
•
Existing environmental and service delivery conditions
Problems in the way services are now accessed and delivered
Specific resources that can compensate for the problems identified
Activities requiring completion to monitor and evaluate service
provision
Senor Carmelo
Page 4
In Section Six, all resources required by Senor
are portrayed. The section
will include will include a description of each service required, its purpose, the
factors that will determine selection of a vendor, and the dates in which the service
will be used.
D. Inclusion of Photographs in the Plan It is impossible to verbally portray
the meager conditions to which Senor
was returned in 1998–almost five
years ago. Although his living circumstances in Mexico before his injury were just
as bleak, his future survival now requires that major aspects of this living
environment change. Photographs taken during the home visit will be used
throughout Sections Five and Six to illustrate the extreme geographic,
environmental, and social deprivation in which Senor
and his family
members live.
E. Recommendations for an Implementation Structure for Service
Continuity and Accountability A complex array of resources must be secured
and coordinated for Senor
benefit if he is to sustain life. Resources
requiring orchestration include such basics as running water, a roof, terrain usable
by his wheelchair, heat, electricity, medications, nutrition, bedding, shelter, medical
supplies, medical equipment, and transportation. Their continued absence will
shorten Senor
life, in the opinion of many of his treating providers in
Mexico and the United States. His likelihood of continued survival will be
measurably increased with access to basic sanitation, hot and cold running water,
adequate nutritional supplements, and an accessible home with a secure roof,
windows and doors.
In Section Seven, the characteristics of a framework for required legal oversight
are presented. Recommendations for workable case managment function for the
family are made, as are recommendations for a workable implementation
structure capable of ensuring accountability for services. An “implementation
structure” that wraps-around the care plan to ensure its adequate governance is
urgently needed. A true case-management function with requisite accountability
and authority for orchestrating all resources should also be established
immediately. On-site case management with the family should now be occurring
with much greater frequency than every ten to thirteen (10 - 13 ) months if the
family is to see any tangible change in their circumstances. As well, the fiction of
investigating possible institutional placements, sanctioned by no treating physician
to date, needs to be abandoned in favor of visible efforts to secure adequate
housing, geographic proximity to services, nursing care, and transportation.
Senor Carmelo
Page 5
II
SECTION TWO
SENOR CARMELO
CURRENT MEXICAN CONTEXT AND SUMMARY OF
WORK-RELATED INJURY
SUMMARY OF MEXICO ECONOMY AND CIRCUMSTANCES Mexico is slightly
less than three (3) times the size of Texas. Its population is slightly over
100,000,000 persons. Geographically, Mexico is a mixture of mountains, high
plains and deserts. Mexico’s natural fresh water resources are scarce and polluted
in the north, inaccessible and poor quality in its center and extreme southeast; with
raw sewage and industrial effluents polluting rivers in urban areas. Due to lack of
controls on major industries, much deforestation has occurred along with
widespread erosion, desertification. The capital of Mexico City has serious air
pollution as do urban centers along the US-Mexico border
Mexico has a free market economy with a mixture of modern and outmoded
industry and agriculture, increasingly dominated by the private sector. The number
of state-owned enterprises in Mexico has fallen from more than 1,000 in 1982 to
fewer than 200 in 1998. The Zedillo and Fox administrations privatized and
expanded competition in sea ports, railroads, telecommunications, electricity,
natural gas distribution, and airports. A strong export sector helped to cushion the
economy's decline in 1995 and led the recovery in 1996 and 1997. In 1998, private
consumption became the leading driver of growth, which was accompanied by
increased employment and higher wages. The economy slowed in 1999 because of
low commodity prices, tighter international liquidity, and slacker demand for exports.
Mexico still needs to overcome many structural problems as it strives to modernize
its economy and raise living standards. Income distribution is very unequal, with the
top 20% of income earners accounting for 55% of income.
Mexico’s economy was negatively affected two years ago, with the net result that
the overall economy is continuing to grow, but its pace has slowed. While foreign
demand, especially for manufactured exports, has registered faster annual growth,
the recovery of the U.S. market is not yet firm. Consumer spending in Mexico is
losing its vitality due to the slow growth of employment and lower increases in
Senor Carmelo
Page 6
wages. Investment is growing only in the construction segment. An important part
of the slowdown in the third quarter was due to the poor result in the farm sector,
and to a lesser extent in industry.
In Mexico, 27% of the people now live below the poverty line. For the Gross
National Product, agriculture accounts for 6%, industry for 26% and the services
industries account for 68%. The rate of inflation is 18.6% per year. In urban areas,
the unemployment rate is 2.6% with considerable underemployment country-wide.
The Mexican labor force is sub-divided by occupation in Mexico as follows:
services 28.8%, agriculture, forestry, hunting, and fishing 21.8%, commerce 17.1%,
manufacturing 16.1%, construction 5.2%, public administration and national
defense 4.4%, transportation and communications 4.1%.
THE
FAMILY AND THE
ENVIRONS The
family lives in a very small village named
in eastern Mexico.
(Locals often comment that the name is incorrect because there is a) no city and b)
no corn). This is an area of Mexico populated with arid and semi-arid scrub lands.
Even during the rainy season, little rain falls. There is one major two lane highway
connecting Cuidad de Maiz with the city of San Luis Potosi. The state in which the
family lives is San Luis Potosi, the same name as its largest metropolitan area.
is a two and one half hour auto ride and a three hour bus trip from
San Luis Potosi, the capital city of San Luis Potosi State. At 1877 feet it is the sixth
highest state in Mexico.
The majority of the San Luis Potosi State population lives in Cuidad de San Luis
Potosi. San Luis Potosi is noted for its academic training and a proliferation of
poorly funded and poorly staffed outpatient clinics manned by general practitioners
of medicine. There are very few American residents within the State of San Luis
Potosi, however. As a result, access to the multiple medical disciplines,
rehabilitation services, home health agencies, outpatient clinics, supply dealers, and
medical supply companies that are present in areas of Mexico with a large US and
Canadian presence (Monterrey, Mexico City, Tampico, Guadalajara, and San
Miguel Allende) are not found here.
There are 1.6 million persons over the age of 12 in San Luis State who are
considered eligible to work. Of this number, 868,000 are judged to be
“economically active” and 860,000 are employed, slightly over 50%. Of the total
population between the ages of 6 to 14, 20% cannot read or write, high even by
Mexican standards, where the average illiteracy rate is 10 - 11% of a States’ total
population.
Senor Carmelo
Page 7
The population density in San Luis is very low, compared to urban areas. In Mexico
State, 180 persons per square kilometer can be found, in the Mexico City, 5360
persons per square kilometer; in Jalisco, 80; in Aguascalientes, 179; in San Luis
Potosi, where over 49% of the inhabitants live outside of urban areas, the
population density is only 36 persons per square kilometer. In San Luis State,
there are 6,757 small localities with fewer than 500 inhabitants. By contrast, there
are 8 localities in Mexico with greater than 15,000 inhabitants, in which slightly less
than half the State’s population resides.
To compare population statistics, the State of San Luis Potosi has 2/3 fewer
inhabitants (2.3 million persons) than the neighboring State of Jalisco and six times
fewer inhabitants than Mexico City. Approximately 860,000 of its 2.3 million
inhabitants are employed, primarily in the manufacturing or service sectors. The
statewide IMSS system of Mexican medical services has fewer than 11% of San
Luis Potosi’s inhabitants as its members. Many sectors of IMSS have recently
done work stoppages, primarily the physicians and nurses, due to inability to obtain
needed medicines and supplies. There are few if any medical clinics for the
average person outside of San Luis Potosi. The Red Cross in San Luis Potosi,
unlike the Red Cross in Guadalajara, charges persons for emergency trips.
As is the case in much of rural Mexico, few state-wide conveniences exist outside of
the major metropolitan areas. Relative to conveniences we all take for granted,
only 64% of Mexican households have a water connection, even though 74.9% of
Mexico’s population resides in areas considered urban. 83.3 % of the Mexican
population has access to safe drinking water. 76.2 % access basic sanitation
services. While there are a total of 252,000 kilometers of highway, paved roads
comprise only 94,248 or 37% of the total roads. Paved roads, last estimated in
1996, totaled 157,752 kilometers, or 63%. There are a total of 232 airports in
Mexico with paved runways but 1573 without paving.
A shift in place of residence has taken place in Mexico since the 1950's. In 1950,
57% of the Mexican population lived in rural areas. Now only 25% do. This shift
means that of the 61% of Mexico’s population resides in urban areas, 47% reside in
areas in size between 100,000 persons to over 500,000 persons. As of the 1995
Mexican census, 51% of the population resided in 7 cities with populations of 1
million or more.
Senor Carmelo
Page 8
Relative to the capability of Mexico to serve its disabled, this capacity has steadily
declined from a high of over 597,000 persons served in 1990 to just over 34,000
served in 1995. As well, DIF, the national organization that provides developmental
and educational services reduced its country-wide caseload from a high of almost
10 million persons served in 1990 to approximately 3,600,000 in 1995. Public
services in Mexico now place primary emphasis on early childhood, obstetrical
services, and services to youth. Literacy services are emphasized and services to
adults are being de-emphasized. IMSS, the state health service in Mexico, restricts
its services and does not serve persons outside of urban areas. To receive surgical
services in Guadalajara, for example, individuals must travel by car or bus the 80
mile round-trip from Lake Chapala to receive services in the city. With social
services declining, hospital services have declined as well. Many funded social
programs receive only staffing grants, receiving such limited funds that staff are
required to seek charitable donations for program necessities or supply their own
office materials and furniture in order to mount a program. Educational services to
young children are now stressed in Mexico with efforts being made to offer flexible
school hours and schedules to keep children from dropping out of school. Literacy
in Mexico is defined as those persons over the age of 15 who can read and write.
With this definition, 89.6% of Mexico’s population is literate.
For a population of almost 2.3 million persons, San Luis Potosi has slightly over
1300 hospital beds spread over 6 institutions; Jalisco by contrast has over 6100
hospitals available spread over the same 6 state institutions. There are 2600
medical staff and approximately 3500 nurses to serve the slightly over 2.3 million
population of San Luis Potosi State. In a country with few resources to expend, it
is not uncommon for nursing homes and hospitals to require that patients supply
their own medicines, meals, equipment, and sheets when staying overnight. Due to
staffing shortages common to most institutions, patients are strongly urged, and in
some surgical cases, required to bring relatives to stay with the them over night to
monitor their relative’s status, give medications, perform dressing and toileting, and
assist in the event of an
emergency. 1
1
Instituto Nacional de Estadistica, Geographia, e Informatica Mexico.
INEGI is the agency in Mexico responsible for integrating Mexico's
systems of statistical and geographic information, in addition to promoting
and orienting the development of informatics in the country.
Senor Carmelo
Page 9
Life expectancy in Mexico is 73.1 years for males, 77.6 years for women, compared
to 73.8 for males and 79.7 for women in the United States. Given these statistics,
Senor
father Porfirio, age 69 in September, has few active years of life left.
In Mexico, there are 120.5 physicians for every 10,000 persons compared to the
United States, where there are 279.9 physicians for every 10,000 persons.
In sum, the area in which the
family lives has few rehabilitative resources
and few practitioners trained to care for catastrophically injured persons residing in
their own homes. Monopolies on services, coupled with low demand have
apparently created a market with few financial options for buyers of services. Few
formal home health and nursing agencies exist in San Luis Potosi as they do in
areas with greater population. Practitioners trained in long-term disability are less
prevalent. As a result, per hour costs for nursing services are significantly higher in
San Luis Potosi than in the parts of Mexico more accustomed to providing nursing
and home health services. Mr.
case manager for Senor
priced
the cost of nursing services, “enfermeras” in May 2001 for Senor
and
obtained a cost quotation of $7.00 per hour for nursing services in
This price is also confirmed by review of bills submitted to
Insurance for
$84.00 per day paid by Senor Porfirio
for twelve hour shifts of care
provided by two nurses. This regionalized cost for San Luis Potosi is more than
twice the cost of nursing services purchased in Guadalajara, MX where $80.00 per
day secures twenty-four hours of care provided by registered nurses with surgical
as well as community-based experience. Prices lower than these were negotiated
in Guadalajara, MX for two registered nurses providing 24/7 care for a patient with
high-level quadriplegia and brain injury in September 2001. Prices last reimbursed
to Dr.
by
to secure ambulance services arranged through
by the physician at $1500.00 are much higher than prices for ambulance transport
that can be arranged through other ambulance services in Mexico. $300.00 per
hour for ambulance transport is significantly higher than costs for ambulance
transport in more populated parts of Mexico where an ambulance equipped with
driver, emergency equipment, and two paramedics can be readily secured for far
less costs. Ambulance service that transport individuals from hospitals in San Luis
Potosi to hospitals in Guadalajara, MX–a five and one half to six hour trip--can
easily be arranged for $500.00 USD or $84.00 per hour.
The prices for long-term care at Nuestra Senora de los Angeles, quoted to the case
manager at $275.00 USD per day ($100,375.00 per year), are two times higher
than costs in other parts of the country. While costs at this hospital can be
negotiated down to $240.00 per day ($87,600.00) this cost is still high in the
Senor Carmelo
Page 10
extreme given the range of qualified, less costly options for long-term care that
abound. Costs for long-term care for medically fragile persons in Guadalajara can
be negotiated and obtained for $85.00 per day in settings where family members
are encouraged to participate in and provide care for their loved ones–a feature not
possible at Hospital de los Angeles. Consumable supplies and durable medical
equipment seem slightly higher in San Luis Potosi than for comparable goods
purchased through Farmacia Guadalajara or available through the country-wide
system of generic pharmacies in Mexico.
BACKGROUND HISTORY FOR CARMELO
The family members of
Carmelo
work as manual laborers. They were raised on an “ejijido”
belonging to their father which is some 15 - 20 minutes outside of
The house is off an unpaved road and the next closest house is a distant one mile
further. The road to the home is rocky and by report, practically impassable during
the rainy season, where it rains daily.
Senor and the now deceased Senora
had eight children. The eldest is
Aron, 44 years, followed by Carmelo, 42 in July, Socorro, 41, Isidro 40, Esteban,
38, Minerva, 37, Adan, 36, and Yolanda, now 26 years. Carmelo
was
born on July 16, 1961.
The majority of Senor
seven (7) siblings have moved away and now only
five (5)
family members reside there–Senor Porfirio
Yolanda, the
youngest, Aron, his eldest son, Carmelo
and Isidro and his family. Senor
Porfirio
reported that his son did not complete “primeria” which goes
through the sixth grade, but was withdrawn from school after the third grade in
order to work with his brothers and father. Withdrawal this early from school is
unusual even by Mexico’s standards, as the average schooling for persons age 15
and over is 7.6 years. Senor
Senior had worked in the United States
through the 60's and 70's in Illinois and Wisconsin as a laborer as did his sons. His
limited English results from that exposure. Senor
mother died in 1983,
twenty (20) years ago, when Carmelo
he was twenty-two (22) years of
age. Senor Carmelo
had never married.
Senor
Senior reported that his son had no major medical problems prior to
his catastrophic injury in 1998, almost five years ago. All of Mr.
24 hour
care requirements are now met by his father, Porfirio and his younger sister,
Yolanda. His sister is responsible for care during the day and the senior Senor
provides care during the night.
Senor Carmelo
Page 11
EMPLOYMENT HISTORY From interview with family members conducted in May
2003, Senor Porfirio
and his son Aron reported that Carmelo
had
worked only in manual labor before his injury.
CIRCUMSTANCES OF WORK-RELATED INJURY As Mr.
cannot report
on the circumstances of his injury, notations from the available records, coupled
with anecdotal reports from family members, will be used. They describe the
following circumstances attendant to Carmelo
injury.
On June 19, 1998, Carmelo
was working for the
Farming
Company in
North Carolina. He, along with 20 other migrant workers,
was employed as a migrant worker to unload watermelons, pick and carry fruit and
work in the warehouse at
Farming. Senor
was directly
supervised by Senor Juan
as the company owners do not speak Spanish. In
addition to supervising the workers which included assigning them to each work day
location, Senor
was responsible for providing the workers with water to drink
and for scheduling their break times. On the day of his injury, Senor
was
assigned to pick tomatoes and place them in buckets that could hold twenty to
twenty-five pounds of tomatoes.
Each worker was required to pick a bucketful of tomatoes and carry the bucket to a
trailer where it was unloaded for grading and subsequent packing.
Workers reportedly took a one hour break from work on July 10, 1998 and then
returned to packing tomatoes. The female co-owner of the company, Mrs. Debbie
worked in the truck trailer packing tomatoes. At about 5:30 PM, she
noticed a group of workers standing at a row and sent their supervisor, Senor
to investigate. By report, Carmelo
was reported to be ill by a co-worker,
but Senor
reported to his supervisor only dizziness. The other laborers
and Mrs.
returned to their work and Senor
sat down until the
others had completed the last of their work. He was reportedly offered water but
no other type of assistance or intervention. At the end of the workday, Senor
was helped to the work campsite by two co-workers as he could not walk
on his own. Senor
was placed on a sheet. At approximately 5:50, the
company co-owner Brent
was informed by Senor
that Carmelo
was ill and called Emergency Medical Services at approximately 6:10 PM,
20 minutes later. Five minutes later, Carmelo
was reported to be
unconscious and EMS was again called. EMS arrived at 6:38 PM and departed
from the camp site at 6:48, ten minutes later. He arrived at the Emergency Room
Senor Carmelo
Page 12
at
Regional Center, at 7:16 PM where he was evaluated by Michael J.
a specialist in internal medicine.
At arrival to the Emergency Room, Senor
temperature was in excess of
108 degrees. By history provided to the physician, Senor
had picked
tomatoes for approximately twelve hours in temperatures of ninety to ninety-five
degrees and humidity of thirty-seven to forty-five percent.
Senor
was packed in ice, diagnosed as having heatstroke, discharged in
critical condition and transferred slightly over two (2) hours later to the University of
North Carolina Hospital where he was admitted to the Intensive Care Unit.
Senor Carmelo
Page 13
III
SECTION THREE
SENOR CARMELO
POST-INJURY SERVICE HISTORY
UNIVERSITY OF NORTH CAROLINA HOSPITAL, CHAPEL HILL, NC Carolina
Air Care airlifted Carmelo
from
Regional Medical Center to the
University of North Carolina Hospital in Chapel Hill, North Carolina on July 10,
1998. Mr.
was noted to be unresponsive, chemically restrained, and
emitting frothy pink secretions his ears and mouth. He was noted to be
unresponsive to any stimuli, to have a temperature of 108 degrees, and was given
a Glasgow Coma Score of 3.2 Senor
was comatose upon arrival to the
hospital and remained so until .
The entire Discharge Summary dictated by Brian
MS IV, for Brian So, MD
is next reproduced in its entirety. Rather than spend time developing a narrative
from Mr.
writings, his actual dictation is presented:
History of Present Illness: Please see admission history and physical. In brief,
the patient is a 36 year old Hispanic male who presented from an outside hospital
intubated and neurologically devastated with a temperature of 108 F. On arrival at
UNC Hospital in became apparent that the patient was experiencing multi-organ
system failure, having insufficient pulmonary, cardiovascular, renal and
hematologic abnormalities. Measures were immediately taken to bring some of
these problems under control. He was immediately transferred to the RICU where
care was begun as outlined in the Hospital Course.
LABORATORY DATA: Laboratory findings on discharge are few, however they
include: white blood cell count 8.9, hemoglobin 9.2, hematocrit 38.9, platelets 438.
Sodium 137, potassium 4.4, chloride 107, C02 25, BUN 8, creatinine 0.6. Calcium
9.8, magnesium 1.5, phosphate 1.5.
2
Carolina Air Care. Collaborative Pre-Transport Patient Assessment. Page 2.
Senor Carmelo
Page 14
Hospital Course: The hospital course is significant for heat stroke complicated by
multi-organ system failure including central nervous system, renal, myocardial,
pulmonary, and cardiovascular involvement as discussed below.
Central nervous system: On admission, the patient was comatose with an initial
head CT unremarkable, as noted above in radiologic studies. The patient initially
had a gradual improvement in mental status with re-acquisition of eye and head
movements, as well as minimal responses to commands. However, the patient
remained paralyzed. At this time, on 08/01, MRI showed diffuse cerebral
infarctions with a small right basal ganglia bleed. On 08/11, the patient had a rapid
deterioration in mental status in that he became unresponsive. Repeat MRI
showed a large right basal ganglia bleed with an associated mass effect.
Neurosurgery placed a ventriculostomy tube at that time. The patient's mental
status did not recover substantially and the tube was removed on 08/19 given the
hemorrhage had stabilized per CT scan. The patient was left in a persistent
vegetative state with the patient's eyes open yet unresponsive to stimuli.
Pulmonary: The patient was intubated at the outside hospital and arrived as such.
He was transferred directly to the Respiratory Intensive Care Unit with developing
acute respiratory distress syndrome. The patient was managed aggressively, and
initially extubated approximately one month later. Through the remainder of the
hospital course, the patient had to be re-intubated on several occasions secondary
to respiratory failure and cardiac arrest. Eventually he was stabilized; however, he
required tracheostomy placement for prevention of aspiration of gastrostomy tube
feedings. He currently has a tracheostomy collar and is maintained on high flow
room air.
Cardiac: The patient was admitted in hypotensive shock which required pressor
agents including Dopamine. He also ruled in for a myocardial infarction during his
initial hospital course. Eventually, he was stabilized and even became
hypertensive requiring treatment with antihypertensive agents including
Hydralazine. His course was later complicated by cardiac arrest, which was
deemed to be pulseless ventricular tachycardia suspected to be secondary to
hyperkalemia. He was resuscitated successfully. During induction for tracheostomy
on 10/02/98, the patient again experienced cardiac arrest which was felt to be
secondary to ventricular tachycardia after receiving succinylcholine. The patient
was again resuscitated successfully and arrest was felt to be due to + hyperkalemic reaction and a tube of succinylcholine given on induction anesthesia.
At this time the patient's cardiac status is stable.
Renal: On admission to the hospital, the patient was found to be in non-oliguric
renal failure felt secondary to the rhabdomyolysis caused by heat stroke. This
worsened becoming oliguric and unresponsive to diuretics. This failure eventually
required numerous hernodialysis treatments, as noted above. Following
hemodialysis, the patient's renal failure recovered. At this time the patient is
demonstrating a picture suggestive of Fanconi's syndrome with marked renal
Senor Carmelo
Page 15
electrolyte wasting. Additionally, the patient's course was complicated by central
diabetes insipidus. This has been controlled and remains controlled with
Desmopressin.
Hematology: On admission the patient had abnormal coagulation studies
consistent with disseminated intravascular coagulopathy. He was treated with
transfusions of fresh frozen plasma, packed red blood cells, .telets, and cryoprecipitants. This was also felt to be secondary to the patient's heat stroke, and
eventually resolved without further incident.
Liver: On admission the patient had mildly elevated liver enzymes. This was
regarded consistent with the patient's hypoperfused state. Liver function soon
returned to normal, and has been such through the remainder of the hospital
course.
Infectious disease: The patient has been treated for numerous pneumonias and
a yeast urinary tract infection. Pneumonias included: aspiration, nosocomial
pneumonia of unknown cause, Methicillin-resistent staph Aureus, and
Pseudomonas. Methicillin-resistent staph Aureus was treated with Vancomycin,
and the most recent sputum/nasal mucous membrane cultures were negative for
Methicillin-resistent staph Aureus. Therefore, contact precautions which were in
place have been discontinued. Currently the patient is being treated with
Ceftazidime and Gentamicin for Pseudomonas infection. These antibiotics are on
day #5 of administration, and should be continued until 10/24/98.
Carmelo
condition required that the following procedures be
completed while at University of North Carolina Hospital from July 10, 1998
to his discharge on October 22, 1998:
7/11/98 - mechanical ventilation begun on admission.
07/13/98 - electroencephalogram (EEG) which showed mild to moderate diffuse
slowing with preserved reactivity to stimuli consistent with mild to moderate
encephalopathy.
08/17/98 - electro-encephalogram severe diffuse background slowing indicative of
bi-hemispheric dysfunction.
07/22/98 - hemodialysis catheter placement.
Hemodialysis performed on numerous days including: 07/25/98, also 07/28/98,
07/30/98, and 8/1/98.
Multiple central lines were placed including: 09/04/98 - right PICC at the brachial
vein, and also 10/07/98 left basilic vein and this line remains in place today.
08/11/98 - left frontal Becker ventriculostomy was performed.
Senor Carmelo
Page 16
09/18/98 - bilateral lower extremity dopplers proved to be negative.
07/10/98 - computerized tomography (CT) scan of the head was
performed which showed no evidence for hemorrhage or mass, no acute changes
were noted.
07/13/98 - lung perfusion scan was performed, the findings of this study were
compatible with low probability for pulmonary embolism.
07/14/98 - computerized tomography (CT) scan of the head without contrast, this
study revealed no change as compared to the CT scan performed on 07/10/98.
There was noted to be an indistinctness of the gray/white matter junction; however,
it had not changed from the previous study, and in the absence of a mass effect, it
was felt to be of questionable significance.
07/21/98 - a portable renal sonogram with doppler flow evaluation was performed.
This showed appropriate flow in the renal veins bilaterally which reduces the
likelihood of renal vein thrombosis. Also noted were hypo-echoic renal cortices.
Elevated resistive indices in the renal arteries were visualized bilaterally. This is
more typical of findings seen in tubulo-interstitial processes or infiltrative processes.
07/23/98 - Magnetic resonance imaging (MRI) of the abdomen. This revealed
decreased cortico-medullary differentiation involving the kidneys bilaterally
consistent with medical renal disease. In addition, there is increased enhancement
of the renal medullas bilaterally consistent with tubular damage. Both the renal
veins and arteries appear patent. Small bilateral pleural effusions and a small
amount of ascites and subcutaneous edema were also seen.
08/01/98 - Magnetic resonance imaging (MRI) of the head, pre and post contrast
MRI study of the brain demonstrated diffuse high signal intensity within the cerebral
cortex suggesting the presence of diffuse lamina necrosis secondary to generalized
ischemia. Findings of diffuse cerebral infarctions were noted, and a small
hemorrhage was seen within the right basal ganglia.
08/06/98 - G tube placement was performed. This was successful and the
gastrostomy tube was placed without complication.
08/11/98 - Magnetic resonance imaging of the brain. A large right basal ganglia
hemorrhage with surrounding ischemia was noted, as was mass effect with midline
shift to the left and sub-falcine herniation.
08/19/98 - CT of the head without contrast. This study was performed status post
placement of a ventriculostomy tube on the left. There was associated new left
frontal hematoma and intraventricular hemorrhage. There was no significant interval
change in ventricular dilatation from previous studies.
Senor Carmelo
Page 17
08/21/98 - CT scan of the head without contrast. A large right basal ganglia
hemorrhage is noted and in the interim, since the last study of the head, the
ventriculostomy tube has been removed. No new areas of hemorrhage are seen.
08/21/98 - portable abdominal ultrasound. Sludge was noted within the gallbladder;
however, no evidence was found for cholelithiasis. No other abnormalities were
noted within the abdomen.
08/23/98 - CT scan of the head. On comparison to previous study performed on
08/21, there is the possibility of a slight increase in the amount of midline shift,
diffuse hemorrhage associated with sub-falcine and downward herniation is still
noted. Partial resolution of some of the blood products seen on the previous study
has occurred.
10/02/98 - CT scan of the chest. No evidence was seen for pulmonary embolus.
There was, however, noted nodular interstitial thickening with peribronchial
thickening diffusely in both upper lobes suggesting infectious causes such as
microbacterial, fungal, or viral infection. Consolidation with collapse of both lower
lobes is seen, and a small pericardial effusion was noted.
Senor
was discharged and sent to Central Hospital in Mexico under the
care of Ricardo
MD. Senor
received the following diagnoses on
discharge:
•
•
•
•
•
•
•
•
•
•
•
•
Heat stroke
Persistent vegetative state
Cerebral infarction
Intracerebral hemorrhage
Acute respiratory distress syndrome
Aspiration
Acute renal failure
Rhabdomyolysis
Cardiac arrest x 2
Myocardial infarction
Shock
Pneumonia
HOSPITAL CENTRAL, SAN LUIS POTOSI, SAN LUIS POTOSI, MEXICO No
records were made available from this hospital for review.
SERVICE PROVIDERS AND THEIR INVOLVEMENT WITH CARMELO
SINCE RETURN TO MEXICO Carmelo
was returned to
Mexico from the United States in 1998. He has received case management
services from December 2000 to the present from
RN, CLCP, a case
manager with Armstrong and Associates in Charlotte, NC. Mr.
is known as a
case manager by this planner.
Senor Carmelo
Page 18
Dr. Raul
Senor
an internist and neurologist, assumed responsibility for
care in 1999 after Senor
return to Mexico, a role Dr.
continues in to the present. Dr.
is both in private
practice and also functions in San Luis Potosi as Regional Director of IMSS, the
national health service in Mexico. He has been instrumental in arranging surgical
procedures, coordinating transportation to medical evaluations and in arranging a
multi-disciplinary series of evaluations requested by Mr.
and held April 2001
and January 2002. He has not had occasion to see Carmelo
since his
departure for an evaluation at Texas Institute for Rehabilitation and Research in
Houston, TX in January 2002--over one year ago. Reportedly, Carmelo
is
seen at his home once per month by Jose Luis Rosas Corona, MD, a physician
affiliated with Farmacia Santa Clara, the local pharmacy in Cuidad de Maiz from
which the family secures some consumable supplies and medications.
Carmelo
was hospitalized briefly for an infection at his tracheotomy site in
Luis Potosi for five days November 23, 2000. He has also had one reported
instance of upper respiratory infection in December 2001. He has had skin
breakdown on his back due to a malfunctioning wheelchair back no longer used.
He has required no other hospitalizations since that time, save for one overnight
hospitalization at Hospital de los Angeles in San Luis Potosi prior to departing for a
scheduled inpatient evaluation at Texas Institute for Rehabilitation and Research in
Houston, TX in January 2002. Upon admission to Texas Institute for Rehabilitation
and Research in Houston, TX in January 2002, it was also learned that the shunt
originally inserted at the University of North Carolina Hospital was replaced, that
Carmelo
had one instance of seizures, and as well, gastric difficulties
since returning to
in 1998, events not recorded prior to that
hospitalization.
Durable Medical Equipment consisting of a lift and semi-electric bed was
purchased in December 2000 for Carmelo
at Especialidades Medico
Quirugicas in San Luis Potosi by
the case manager for Carmelo
Mr.
a Registered Nurse and Certified Life Care Planner, is
employed by
North Carolina. This was case
manager
first of three visits made to visit Senor
On his first on-site
visit with Senor
in December 2000, Mr.
conducted a physical
examination of Senor
and his living environment. He also purchased
equipment for Senor
consisting of an Invacare 5001 bed and lift. Mr.
secured two blankets, two pillows, as well as sterile gloves, Shiley cannulas, Foley
catheters, and other consumable items at that time as well.
Senor Carmelo
Page 19
Mr.
next visit occurred thirteen (13) months later when he traveled to Mexico
January 2002 to complete an on-site review of a long-term facility, Hospital de los
Angeles. At that time, the following supplies were purchased by Mr.
20 cases
of Affective #10 diapers, 6 #10 Shiley tracheostomies, 14 Foley catheters, 30 bags
of IV Saline, 14 Desvarset Maxi-drip tubing, and 10 bottles of alcohol solution. Mr.
also sought, prior to his arrival, to develop an arrangement with the supply
distributor whereby supplies would be routinely delivered to the
family. His
notes do not reflect whether this arrangement was secured or not. His on-site visit
was immediately prior to Senor
departure for Texas on January 29, 2002.
Senor
was admitted to Hospital de los Angeles on January 28, 2002 to
allow the San Luis Potosi hospital to evaluate him for possible long-term placement
upon his return from Texas Institute for Rehabilitation and Research, where he was
also scheduled for an evaluation requested by Mr.
that started on January 29,
2002. Ultimately, Senor Porfirio
declined to have his son placed in the
facility as the hospital was unwilling to allow him to provide care to and stay with
his son overnight at that facility. Heretofore, Senor
Senior had been
willing to consider institutional placement as long as he was able to provide some
aspect of care to his son when in an institutional setting. When this was not
possible, he refused this setting.
Mr.
next flew from North Carolina to Houston, TX on March 1, 2002 to attend
the Discharge staffing held for Senor
at Texas Institute for Rehabilitation
and Research (TIRR) in Houston, TX on March 11, 2002. His available records
confirm that he returned to North Carolina with copies of some aspects of the
records for Senor
It is not known whether he requested a full copy of the
record.
Mr.
next case management contact with the
family occurred ten
(10) months in late December 2002 when Mr.
delivered the wheelchair
prescribed March 2003 for Senor
by TIRR staff. For that visit, he also
secured 72 packages of Adult diapers, 30 bottles of saline, 10 IV tubing, 4 #26
French Foley catheter to be used for gastrostomy tubes, 3 #10 Shiley cannulas for
tracheostomy replacement, and 12 boxes of gloves which he delivered to the
home. He has had no further visits with the family since then. Attorney
has indicated that in correspondence from Mr.
Mr.
is now
approved for one on-site case management visit per year to the
family by
the insurance carrier,
Insurance. Mr.
also conveyed that in Mr.
has been given permission to prepare a life care plan for Senor
in
September 2003.
Senor Carmelo
Page 20
Between September 2002 and June 2003, a time period of some ten (10) months,
no further reports have been developed by Mr.
No additional visits to Mexico
are noted as being planned and the file is noted as having “no activity” in January
2003 after several months. There does not seem to be an active Rehabilitation
Plan and as stated above, no Life Care Plan has been prepared summarizing Mr.
conclusions regarding the needs of Senor
TEXAS INSTITUTE FOR REHABILITATION AND RESEARCH Aspects of the
Discharge Summary prepared on March 19, 2003, by Magda
MD and
reviewed by
MD, Assistant Director, Brain Injury Unit, Texas
Institution of Rehabilitation and Research, are next presented. As with the
Discharge Summary from University of North Carolina Hospital, no time will be
utilized to formulate a narrative extracted from this summary. The summary is
quite detailed and speaks for itself:
DATE OF ADMISSION: 01/29/02
DATE OF DISCHARGE: 03/11/02
REASON FOR HOSPITALIZATION: Rehabilitation status post brain
injury secondary to heat stroke, in permanent persistent
vegetative state.
HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old male and
with a diagnosis of anoxic brain injury secondary to heat stroke on 07/10/98, whileat work in North Carolina. His course was complicated by renal insufficiency and
cardiopulmonary arrest. The patient also required tracheostomy and G-tube
placement. His acute hospital course was also complicated by pneumonia on
10/23/98. He was transferred to Mexico for further management. The patient also
has a history of hydrocephalus, status post ventriculoperitoneal shunt on 06/17/99;
seizure disorder tonic clonic x one; with no medical treatment; and gastric ulcer on
06/21/99. The patient has been treated with family in Mexico, followed by
enterologist Dr. Raul
He was transferred to TIRR on 01/29/02 to address
his rehabilitation needs and for family training.
PAST MEDICAL HISTORY: As above.
ACTIVITY LIMITATIONS ON ADMISSION:
1.
Inability to ambulate.
2.
Inability to perform activities of daily living.
3.
Inability to perform basic mobility.
4.
Severely impaired cognitive and communication skills.
INVESTIGATION:
1.
Doppler performed on 02/02/02 showed no evidence of deep venous
thrombosis in the lower extremities. The popliteal veins could not be
Senor Carmelo
Page 21
imaged bilaterally; clinical correlation recommended. The study was
technically difficulty due to his spasticity.
2.
On 01/30/02 chest x-ray showed minimal left lower lobe retrocardiac
atelectasis.
3.
On 02/01/02 chest x-ray showed moderate pulmonary vascular congestion.
4.
On 02/07/02 x-ray of the right wrist showed diffuse osteopenia throughout
the right wrist with no acute fractures of dislocations. fractures or
abnormalities but diffuse osteopenia, most prominent in the periarticular
region.
5.
On 02/07/0/2 x-rays of the spine, three-views showed diffuse osteopenia
over the visualized skeletal structures, ventriculoperitoneal shunt visualized
overlying the left posterior aspect of the skull. No gross abnormalities in the
sinuses.
6..
On 02/07/02 left hand x-ray, two-views showed no gross abnormalities.
7.
On 02/07/02 right ankle AP and lateral views showed no acute fractures or
dislocations, soft tissue swelling at the ankle. Diffuse osteopenia of the
visualized skeletal structures, fractures identified. Osteopenia of the
visualized skeletal structures, dislocation, mild osteopenia of the visualized
skeletal structures.
8.
On 02/07/02 right knee x-ray two-views showed no gross fractures
identified. Osteopenia of the visualized skeletal structures, dislocation, mild
osteopenia of the visualized skeletal structures.
9.
On 02/07/02 right hip x-ray showed no acute fractures or dislocation, mild
osteopenia of the visualized skeletal structures.
10.
On 02/07/02, right elbow AP and lateral showed no acute fractures of
dislocations. Periarticular osteopenia intensified formation from the
olecranon process.
11.
On 02/07/02 left shoulder x-ray two-views showed the patient's shoulder in
internal rotation. No fractures. Partially visualized retroperitoneal shunt in
the left hemithorax.
12.
On 02/26/02 skull series showed ventriculoperitoneal shunt not visualized
in its entirety, secondary to overlying projection of skull bone. However, the
visualized portion demonstrates no evidence of disruption. The shunt
appears across the midline.
HOSPITAL COURSE: Mr.
following:
Senor Carmelo
Page 22
hospital course was remarkable for the
Respiratory: He was downsized to a #6 tracheostomy. He was found with thick
secretions and was started on aggressive pulmonary toileting, with improving
respiratory function.
Gastrointestinal: The patient had coffee ground emesis on 02/01/02. He was
cleared with one lavage. Gastroenterology services was consulted. They
recommended H2 blockers and lavage p.r.n. No esophagogastroduodenoscopy
was needed at this time. The patient also vomited his tube feeds on 02/07/02 and
his tube feeds were held. Eventually his emesis resolved on its own and
the patient was restarted on his tube feeds with low residuals.
Infectious disease: The patient spiked a fever of 102 OF on 02/01/02. He was
placed on a broad-spectrum antibiotic treatment. Cultures taken from blood, urine,
and sputum. The patient was found to be tachycardic with a temperature of 103 OF
and was found to be hypotensive. He was transferred to Hermann Hospital, where
he was treated for urosepsis, then transferred on 02/05/02. He was kept on
antibiotics until he completed his course at TIRR. The patient eventually did not
develop any other infectious disease issues.
Neurologic: The patient had an MRI of the brain to rule out hydrocephalus. The
reading was positive for hydrocephalus versus and the patient was deemed a poor
candidate for further surgical treatment. Dr. Mims was consulted for further
recommendations.
Musculoskeletal: The patient was started on a casting regimen for the upper
extremities. He was examined under general anesthesia on 02/21/02. The patient
was found to have contractures on the upper and lower extremities, and was started
on antispasmodics, with good results.
TREATMENT RENDERED: The patient had involvement of physical therapy,
occupational therapy, skilled nursing and medical care.
PROCEDURES PERFORMED: None.
GENERAL: The patient is unresponsive, lying in bed comfortably, with decerebrate
posture.
HEENT: Pupils were equal, round and reactive to light. The patient with no tracking.
Pink and moist oral mucosa.
LUNGS: Essentially clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs or gallops
appreciated.
ABDOMEN: Soft, nontender, non-distended. PEG site is clean with dressing
applied.
EXTREMITIES: No edema in the bilateral lower extremities.
Senor Carmelo
Page 23
NEUROMUSCULAR: The patient was making nonpurposeful movements. He does
not follow commands and is nonverbal. The patient has increased tone in the
bilateral upper and lower extremities. Unable to assess sensory. Deep tendon
reflexes show bilateral patellar reflexes and biceps and triceps increased. Motor
strength was unable to be assessed secondary to his vegetative state.
CONDITION UPON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1.
Prevacid 30 mg per PEG q.h.s.
2.
Albuterol and Atrovent nebulizer treatments q. 8h.
3.
Baclofen 10 mg per PEG q.i.d.
4.
Dulcolax suppository q.h.s.
FINAL DIAGNOSES AND IMPAIRMENTS INCLUDING PA1
1.
Status post anoxic encephalopathy.
2.
Spasticity.
3.
History of shunt on 06/17/99.
4.
Seizure disorder
5.
History of gastrointestinal bleed and gastric ulcer.
6.
Status post tracheostomy.
UNMET GOALS TO BE ADDRESSED AFTER DISCHARGE: None.
DISPOSITIONS, INSTRUCTIONS, AND FOLLOWUP: The patient was discharged
home to Mexico with his father. He was provided a wheelchair and suctioning
achine. He will be followed by his neurologist at home.3
CURRENT STATUS OF GOODS, SERVICES, AND PROJECTED CASE
MANAGEMENT CONTACTS FOR THE
FAMILY Multiple
recommendations were made for Carmelo
upon discharge from TIRR. The
prescription medicines prescribed have already been reviewed and only the
Albuterol is used at the present. It should be noted that Senor
was
provided with two months’ worth of supplies and medications upon discharge from
TIRR. Senor
and his daughter, Yolanda, were trained in many aspects of
Senor
care and have made judicious attempts to conserve what supplies
from TIRR that they can in the year and one-half since Senor
was
discharged. Some aspects of Senor
daily regimen were changed at TIRR,
for example, he was down-sized to a #6 Shiley tracheostomy tube. The reduction in
size of the tracheostomy tube recommended for Senor
may not have been
reviewed at the Discharge Staffing Mr.
attended, for supply re-ordering
3
Magda, MD. Discharge Summary. Texas Institute for
Rehabilitation and Research, Baylor College of Medicine, Houston, TX,
March 19, 2002.
Senor Carmelo
Page 24
completed by him in September 2002 attendant to his last trip only reflects the
obsolete #10 size formerly used.
An audit was completed of all supplies prescribed and available at Senor
home in May 2003. An audit was also completed of the entire TIRR medical record
obtained during on-site consultation with
MD on June 2, 2003.
These two audits indicate that equipment and many supplies prescribed for Senor
by TIRR and sent with him into Mexico have not been re-ordered since his
discharge March 2002. Due to this oversight, this planner chose to order and have
shipped to Senor
the #6 Shiley tracheostomy tubes prescribed for Senor
at the TIRR evaluation. This planner also re-ordered the #1853 HydroTherm w/lever lock device Senor
Senior and his daughter were trained to
use at TIRR. At discharge, Senor
was provided with one box of 50
devices–sufficient to last two months. They have carefully cleaned and re-used
each device as long as possible and made every attempt to conserve them. Despite
these measures, only ten (10) were left at the time of the home visit in May 2003.
Two boxes containing 200 of these prescribed devices were ordered and shipped in
care of Farmacia Santa Clara to reduce the likelihood of infection for Senor
ill with an upper respiratory infection at the time of the home visit. This planner has
as a
also arranged for rental of an O2 concentrator to be shipped to the
safer and more cost-effective alternative than the bottled gas now used. A newer
nebulizer model is being shipped this week to replace the out-dated Yeong Chi
model provided to the family, as well as100 new syringes for bolus feedings, and
four (4) crates of Ensure to supplement the family’s having to rely on preparing a
blender full of pureed chicken, beets (“betabel”) Carnation milk, carrots, lettuce,
bananas, cereal, Karo syrup, and “chayotes” for Senor
daily feedings.
Senor Carmelo
Page 25
IV
SECTION FOUR
SENOR CARMELO
METHODS USED TO INVESTIGATE LONG-TERM NEEDS
RECORDS AND TEXT REVIEW The following records were received and reviewed
as part of this planning process:
Ph.D.4
•
Deposition and Life Care Plan Prepared by
•
Deposition of
•
310 Pages of Progress Notes, Bills and Miscellaneous
Correspondence Maintained by
RN, CLCP, Case manager,
NC
•
University of North Carolina Hospitals Medical Record, Chapel Hill,
NC5
•
Texas Institute for Rehabilitation and Research, Houston, TX6
RN, CLCP
INTERDISCIPLINARY PLANNING EFFORTS: CONSULTATION WITH LUIS
MD A site visit was accomplished at the request of
J.
Attorney at Law, by this planner and an associate flying to San Luis Potosi,
MX on May 5, 2003. The purpose of the trip was to consult with
MD and complete a home visit with Carmelo
and his family members.
The first consultation was completed with Dr.
the evening of May 5, 2003 and
4
185 Pages
5
1,323 Pages
6
623 Pages
Senor Carmelo
Page 26
the second on May 7, 2003. During the first consultation, Dr.
outlined his
service history with Carmelo
the most pertinent health and safety risks he
feels are presented by the current living environment, his treatment history including
intra cranial valve replacement, the history of respiratory, pressure ulcer and
nutritional issues, and his conclusions about the capability of the family to care for
Carmelo after such a long period without nursing supports. Family burn-out was
discussed as a pertinent concern as were the obvious geographic restrictions to
service inherent in their current location. Following the home visit conducted in
on May 6, 2003, this planner again met with Dr.
for an early
morning consultation to brief him on pertinent family dynamics, the obvious “burnout” and risk for illness of family members now have occasioned by their almost
continuous lack of regular sleep cycles. The obvious clinical depression apparent for
Yolanda, Carmelo
sister, was reviewed as well.
Steps and strategies that could be used to persuade Senor
Senior to move
his family closer to medical services were discussed. Dr.
viewpoints were
sought on the merits of an inpatient evaluative stay at San Javier Hospital in
Guadalajara, MX. He was most supportive of and endorsed the idea as a means to
acquaint Senor
with the benefits of medical services in Guadalajara, and in
fact, agreed to participate by traveling to Guadalajara in his role as attending
physician to participate in the Discharge staffing if such a stay could be arranged for
early fall. He agreed to assist by also presenting to Senor
Senior the
geographic, service, cost, and living benefits inherent in residing in one of the
Guadalajara colonias, or at Lakeside and its environs, where rural life more similar to
that in
can be obtained, but with many more conveniences.
The range of services, providers, diagnostic work ups, routine blood work, G-tube
replacement, durable medical goods, transportation, medications, and the entire
range of goods affirmed by Dr.
can be found in the Resources section of this
report.
INTERDISCIPLINARY PLANNING EFFORTS: CONSULTATION WITH LOCAL
SUPPLIERS Senora Maria Balbina
was contacted during the site
visit to
She did not, due to the type of pharmacy she owned, have
the capability to produce a detailed bill summarizing all the goods and supplies
provided to Senor
in the last several years to document the frequency of
use, replacement cycle, and numbers and varieties of supplies utilized. She was
most cordial and offered to reconstruct the supply list from memory but was not
asked to do that.
Senor Carmelo
Page 27
INTERDISCIPLINARY PLANNING EFFORTS: CONSULTATION WITH
MD This planner flew to Houston, TX June 2, 2003 in order to consult
with
MD, Assistant Director, Brain Injury Program, Texas Institute
of Rehabilitation and Research, Baylor College of Medicine and obtain his
recommendations for services. Dr.
confirmed that Carmelo
brain
damage is significant, wide-spread, irreversible and that his life expectancy, with
appropriate intervention, could be between 10 to 12 more years. He also estimated
that Carmelo
functioning is between a 1 and 2 on the Rancho los Amigos
Scale of Brain Injury Functioning. This scale, developed by staff at Rancho los
Amigos provides a quick and easy descriptive way to appraise an individual’s ability
to respond to his circumstances. It is reproduced in the Appendix of this report to
provide the reader with a ready means to gauge Carmelo
vulnerability and
his lack of capability to respond to any aspect of his environment.
Considerable time was spent discussing family dynamics, the condition of the family
home, its distance from any services, the deplorable lack of modern features–space,
heat, toilets, telephone, sterile hot water-- attendant to Carmelo’s stay there for the
last 5 years-- and the health risks these conditions posed for him. Priorities for a
case manager seeking to advance greater proximity of care and basic sanitation for
the
family were discussed, as were family dynamics of importance.
Strategies to use in working with Senor
Senior were reviewed as were the
behaviors of Senor
toward nursing staff during Carmelo
inpatient
stay. The extreme care-giver burn-out and depression observed in both family
members was reviewed with Dr.
as a function of five years of continuous
care giving.
Ways to bring about a geographic change for the family were reviewed. The wisdom
of seeking an outcome that would be of demonstrable benefit to Senior Senor
was reviewed and endorsed by Dr.
The steps to secure an
evaluation at San Javier Hospital in Guadalajara in which Dr.
as treating
physician, could participate as well as Senior
and his daughter, was
approved by Dr.
as a way to not only to obtain current baseline on Senor
functioning, but to permit adherence to the every 6 month G-tube change
and trach tub change, recommended by TIRR over thirteen months ago. A plan to
couple active work with the family, coupled with other actions that could affect a
geographic move and place the
family closer to more competitively
available housing, goods and services was also reviewed.
Senor Carmelo
Page 28
Difficulties in securing appropriate supplies and equipment were discussed, as was
the dubious utility of using a Solara wheelchair designed for sidewalk use in a rough
terrain environment like
This planner’s intent to include a
wheelchair in the Life Care Plan that not only could be secured at Everest and
Jennings or Invacare in Guadalajara, but one with larger tires to permit operation on
cobblestones or rocky terrain, was endorsed by Dr.
as realistic. Dr.
recommended that, at this point, Carmelo
care needs could be
met by a bi-lingual well-trained, very patient internist, as opposed to specialist in
rehabilitation medicine. Continuation of neurology care was also recommended to
ensure monitoring of Carmelo
shunt. Provision of weekly in-home nursing
evaluations, coupled with reliance on highly trained home health aides for daily care
was recommended by Dr.
as was use of adapted transportation to ensure
access to services, and, acquisition of accessible, clean and up-to-date housing
resources. Purchase of all equipment recommended by TIRR staff in March 2002
for positioning of Senor
is included in the Plan, as are efforts to secure the
supplies prescribed for Senor
Greater continuity of case management
services is recommended as well to assist the family in bring about the geographic
transition they need to make for their disabled relative.
In summary, all of the items agreed to by Drs.
life care plan for Carmelo
and Dr.
make up the
INTERDISCIPLINARY PLANNING EFFORTS: CONSULTATION WITH KEITH
SOFKA, LICENSED ASSISTIVE TECHNOLOGY PROVIDER Keith Sofka, partner
to Dr. Caragonne in Caragonne and Associates, LLC, participated in the in-home
assessment of Senor
in a capacity as a designer of accessible
environments for persons with disabilities. His recommendations on features
needed in an accessible home were discussed with and approved by Senor
during the home visit. These recommendations for architectural modifications
appear in the Life Care Plan, as are his other observations regarding both the
frequency and content for future case management service delivery.
PLANNING EFFORTS WITH SENOR CARMELO
This planner’s
conclusion that appropriate, accessible housing be secured for Carmelo
was reviewed with his father with his father in agreement that a change would be
beneficial. Senor
as well conceded the benefit of an inpatient stay in
Guadalajara in September 2003 to identify physicians that could treat his son, and,
expressed much interest in promptly securing this evaluation. He agreed to having
ambulance transportation arranged for his son to travel to Guadalajara and
Senor Carmelo
Page 29
evidenced strong interest and willingness to explore other housing options. He and
his daughter agreed that the daily care responsibilities shouldered to date were
wearisome.
Yolanda, Senor
sister, stated she is now sad “todo tiempo” all the time, for
her brother, that her work is without end, “el trabajo estáá sin un extremo”, and,
further that “a partir de tiempo al tiempo, pierdo toda la esperanza que seráá
siempre diferente”... ”from time to time I lose all hope that it will ever be different.”
Both agreed to work with a case manager to explore other options for care that could
keep their son and brother residing with them, yet offer him a higher level of
services.
Senor Carmelo
Page 30
V
SECTION FIVE
SENOR CARMELO
CONCLUSIONS MADE AFTER HOME VISIT, RECORDS REVIEWED,
AND CONSULTATION WITH TREATING PHYSICIANS
THE
“EJIJIDO” The
family
homestead was reached at 9:45 AM,
Wednesday morning, following a three (3) hour
bus trip. Attorney
Keith Sofka and this
planner arrived and walked the three blocks to
Famacia Santa
shown below, to meet the
owner, Senora Maria
and secure
some form of transportation to the home.
Transport in the back of a flat-bed truck was
secured to the
family’s home. The
family lives 20 minutes outside of
on the road shown to the left. As one
drives out of town, telephone lines cease. Road
surfaces deteriorate. Housing size and density decreases and electric lines become
fewer and fewer. A cattle-guard and open gateway marks the beginning to the “ejijido”
or Indian owned land in which Senor
and his family maintain property. A driver
veers to the left from the main thoroughfare to enter the section of lands on which the
family and others maintain
homesteads. The properties are largely
untilled farm land with cows, horses, burros,
and cinder-block shacks. There is no
transportation from the city to this property;
no taxis in the city, and most people walk the
distance from the “ejijido” to
eleven kilometers away. No houses signify
the way to the property and it remains
primarily somewhat densely forested,
uncultivated scrub land. The
homestead sits on the right after completing
Senor Carmelo
Page 31
the short drive to the property.
The gate shown in the picture to the right marks
the
property entrance. As can be
seen, a dusty and rocky path leads to the oneroom cinder-block dwelling in the back that
houses Carmelo, his father and sister. Other
cinder-block houses dot the property, the
majority of them vacant and unused as other
family members have moved away, married, or
have left for the US to look for work. A
deteriorating adobe wall fronts the path on the
right of the path to the little house. Chickens
and roosters flock along the path as shown in the picture below. A laundry is drying on
the line to the left of the walkway confirming that Yolanda has, as is the case daily, just
washed one of Carmelo’s three sets of sheets and is drying them in the sun. Five
meters behind the cinder-block house sits a
neighbor’s property, much coveted by Senor
and Yolanda, as it has a real
“sanatoria” (bathroom), a sewage line and hot
and cold running water.
CURRENT HOUSING “RESOURCES” The
outside of the cinder-block shacks, originally
visited by Case Manager
Attorney
and Attorney
in late December 2000 is
pictured to the left and above. On the next
page is the cinderblock dwelling shared by
Porfirio
his son and daughter. The
inside of the shack measures 7 x 6 meters.
Three people live in a space of approximately 23 x 20 feet–slightly larger than the size
of a one car garage in the United States.
Carmelo
has been cared for in these
cramped quarters since his return from the
United States in October 1998–four years and
seven months ago. The living space is dark on
the inside with only one bare bulb from the
ceiling and the side windows blocked with card
board. The roof, shown below, is made of
metal and covered inside with cardboard boxes
to keep rain from falling on Carmelo. When it is
rainy season and mosquitos abound, a white
lace scarf is placed over Carmelo’s head to
keep the bugs from landing on his face.
Senor Carmelo
Page 32
Carmelo’s bed is placed in the center of
the room. Approximately two feet of
space are available on either side of the
bed for a walkway, less than one foot is
available at the end of the bed because
the Solara wheelchair is stored there,
and two feet at the head of the bed are
available where a person can stand to
do suctioning once per day, bolus
feedings five to six (5 - 6) times per day,
and nebulizer treatments four (4) times
per day. At the eastern wall of the
building, a long table is used to house
the nebulizer machines, two suction machines (one broken), bottles of Lubriderm,
various boxes of diapers (three left at the time of the home visit).
The oxygen tank sits in the corner to the left and on the right is the Hoyer lift, a fan,
boxes of gloves, extra sheets, and leg splints prescribed for Carmelo’s use at TIRR.
The wheelchair purchased in November 2001 could not be located. The bed obtained
by Case Manager
for $1500.00 through the Mexican durable medical supplier is
shown in the picture below left. At the north end of the room is a refrigerator and
bottles of water. A table with a white plastic tablecloth is the location for many of the
supplies used. It houses the bowl containing the six bolus feeding tubes which are left
(picture above), an admixture of vent
tubes, gloves, prescription medicines,
Gingko biloba (prescribed by a curandero
to improve Carmelo’s memory), syringes,
Jarabe cough syrup, Baby Magic, gauze,
Carmex for Carmelo’s dry lips, scissors, a
box of suction tubing, #28 French Foley
catheters, Dermodine solucion, vegetable
oil, Karo syrup, bottles of Ilosone liquid,
B-12 Elixir (for memory), Solucion CS for
Flex-o-Val, sodium chloride used for
breathing treatments, injections, Vino
Medicino, a naturopathic medicine, cotton
balls, and various antibiotics used for the
frequent upper respiratory infections
Carmelo now gets–Erythromycin, Gentamicin, and Ampigen injectables. The table
houses a small spiral notebook into which Yolanda meticulously notes the progression
of each day, what treatments she performs at what time, for her brother, and what
supplies were used.
Senor Carmelo
Page 33
Carmelo
is pictured at the right. Although
the pictures do not reflect it, Carmelo
has
significant contractures in his hands and feet. The
positioning program prescribed by TIRR has
apparently not been able to be maintained in the
absence of the bolsters and positioning devices
prescribed. His toes and fingers can be pried open
with great difficulty for cleaning, reported his sister.
His skin was of good color, not thin, with no
pressure ulcers. He had a significant raspy cough
with much mucous, necessitating that Senor
request of this planner a shipment of the
#1853 Hydro-Therm w/lever lock devices,
prescribed in March 2002 and now almost used up.
To the right of the door
is the bed used by
Senor
and his
daughter. Senor
arises every two hours at night
and turns his son. Yolanda
does the same in the
daytime and both are responsible for getting Carmelo out
of bed and into his wheelchair for 2 - 3 hours per day.
Both are responsible for maintaining the passive range of
motion exercises they were taught at TIRR. Yolanda is
responsible for changing Carmelo’s diapers 6 - 8 times per
day and for preparing
the pureed mixture of
food she creates in a
blender that she later puts into his Carmelo’s Gtube. Carmelo is suctioned once per day. Carmelo
receives frequent bolus feedings and does not have
apparent access to the prescribed nutritional fiber
recommended by TIRR. Carmelo
is
bathed in bed using cold water and a sponge.
Carmelo’s tubes, vent and trach devices are also
cleaned with cold water and vinegar. Devices that
directly enter his throat cannot be sanitized, nor
apparently, replaced with regularity.
When Carmelo
is placed in his chair the
requisite hours per day recommended, the only
space available in which to wheel his chair is
immediately outside the front door on a small
Senor Carmelo
Page 34
covered plywood porch. Senor
sub-standard and cramped environment lacks
a telephone, reliable electricity, a cistern,
running water, heat, an adequate roof and
floor, indoor plumbing, no capability to
sterilize devices he has to rely upon to
breathe, and lacks adequate living space in
which to move and transfer him from bed to
wheelchair. There are no bathing facilities.
Family members are required to perform all
personal activities with little regard for
dignity and privacy. Senor
has
little to no access to the outdoors given the
type of tires on the wheelchair purchased
for him. He requires medical attention for his cough and surgical intervention to remove
the growth on his left ear that has grown back.
In this environment lacking even basic shelter, funding made available to the family has
been prioritized as follows: Senor
was provided a lift that can only be used if
available furniture is moved each time the lift is used. Senor
was provided that
does not raise to assist care givers in caring for Senor
a bed lacking a
mattress that can prevent skin breakdown. Lastly, he was provided with a $5,000.00
wheelchair designed for use in an urban environments and unusable in the terrain
where he resides.
Risk Factors for Senor
If Senor
is forced to remain in his current
living environment, he will remain at risk for continued upper respiratory infections and
pneumonia. Infections are now being treated, they are not being managed. He has
developed extensive osteopenia due to his immobility and is at risk for limb fractures
and breakage during transfers.
He is at risk for nutritional deficits and
infection given current methods of feeding.
TIRR staff note on March 11, 2002 that
putting food or other liquids through his
PEG tube was not recommended due to
increased risk of clogging or infection.
He is at risk of decreased
respiratory/pulmonary exchange. He has
no opportunity to interact with his
environment, however minimally. He has
no current access to a bilateral upper
Senor Carmelo
Page 35
extremity or bilateral lower extremity bed positioning program that will inhibit abnormal
tone and increase his available range of motion.
He is at risk of aspiration secondary to his
cognitive deficits. He is at risk of deep vein
thrombosis secondary to decreased mobility.
Given the limited amounts of time he is now in
the wheelchair, he is at risk of developing
increased tone. The objective of extensive bed
positioning efforts and wheelchair positioning
activities completed by TIRR staff were in
service of decreasing his tone. The wheelchair
prescribed was designed to improve his
respiratory status and inhibit tone.
Risk Factors for Care Givers Respite care
givers and home therapy were key aspects of the program recommended by TIRR.
This have not been obtained since his discharge March 2003, leaving his two family
members with sole responsibility for his daily care, once again. Senor
is at
near coma level of functioning as ascertained by TIRR staff on February 25, 2002. He
was noted to be consistently responsive to stimulation presented to 2 sensory
modalities and partially responsive to commands. Although the actual extent of his
abilities to comprehend may be highly limited, continued facilitation of communication,
recommended by TIRR staff, will be difficult to execute with concomitant care giver
burn-out, depression, and despair.
Considerable funds were expended for the TIRR evaluation. Presumably the evaluation
was requested to secure the recommendations of highly skilled treatment staff. Were
that to have been the case, after treatment recommendations were obtained, case
management contact after March 2002 would have been increased to implement the
recommendations made. This has not been the case.
Inexplicably, case management contact, already at insufficient levels to permit work with
the family, were reduced to symbolic levels only after March 2002. The once per year
level of on-site contact now allowed the non-Spanish speaking case manager is grossly
insufficient if substantive change in the patient’s circumstances is anticipated–or in fact,
desired by the insurer. Change cannot occur under circumstances marked by
language incompatibility, temporal inconsistency and cultural innocence. If change is to
occur, the case manager must be given sufficient time–and language tools--to execute
a plan of service that will prolong–not suppress-Carmelo
life.
OVERALL PLAN OBJECTIVES OF SAFETY, HEALTH AND CONTINUED LIFE This
care plan has three over-arching goals for Senor
ncreased safety, increased
Senor Carmelo
Page 36
health, and a lifespan not precipitously shortened by further medical and service
neglect. He is manifestly unsafe in his current environment. He is obviously unhealthy.
And he is receives neither the proper amount of case management services nor
services targeted toward changing his living conditions.
APPROPRIATE HOUSING AND MODERN MEANS TO COMMUNICATE A six months
time-frame must commence, characterized by active on-site work with the family that is
targeted toward tangibly changing their living circumstances, and, their attitudes toward
change. Time must be expended by the case manager on-site one week per month,
once accord is reached on plan objectives (however that “agreement” is reached). The
case manager must be permitted–and required--to extend active outreach to the family
in service of helping them reach a decision to move to a new, more healthy
environment. The family needs to be given sufficient time to reach this conclusion. Six
months of intensive case management effort, coming on the heels of two to three years
of benign neglect, does not seem unreasonable. If, after six months, it does not appear
to be likely that this decision can be made by the family, then the adjustments
necessary to their current living environment must be made and a new home
constructed. A new home with plumbing, telephone, such luxuries as hot and cold
running water and indoor must be extended to the
family by the case manager.
It is recommended that a move from their current location even occur prior to their
supporting a geographic move. Rental housing is easily available in
and in San Luis Potosi. Removing Senor
from the deplorable conditions in
which he resides is a priority.
The strategy selected to secure the family’s endorsement of a geographic move is that
of an inpatient stay at San Javier Hospital. As the first step recommended, this
hospitalization should be contemporaneous with time spent showing the family the
tangible benefits of greater proximity to medical care. Such other benefits as provision
of adapted transportation should occur during this time. All efforts made with the family
should be in service of seeking to restore to them some degree of the control they have
lost attendant to their loved one’s injury. Activities with the family should not be at arms
length. A relationship with the family is the vehicle through which they can better
understand the benefits of a geographic move and is the means through which Carmelo
circumstances can be changed. Attempting to short-circuit development of a
relationship, as has been the case in the past, has been manifestly unsuccessful.
Equally unproductive will be any extension of efforts to by-pass the family, significantly
Senor
as head of the household.
ACCESSIBILITY OF ADAPTIVE TRANSPORTATION The family has no
transportation that protects their family member. Traveling in the back of a pickup truck
to medical appointments is not an appropriate means to transport a significantly
disabled person. Adapted transportation in the forms of light vans is easily available in
Mexico, economical to use, and quite accessible by US pricing standards. Newer
Senor Carmelo
Page 37
Nissan models and models from Italy are cost-effective, light weight and will decrease
reliance on cumbersome ambulance services and concomitant scheduling.
AVAILABILITY OF MEDICAL SERVICES Services to the family are practically nonexistent. The first target objective is greater geographic proximity to medical services, if
that can be reached. If not, then more frequent case management contact is dictated to
monitor the changes in patient condition. The infrequent contact permitted Case
Manager
to date and the language incompatibility so apparent in his recordings
meant that the seizure disorder and gastric condition experienced by Senor
were not known until the TIRR staffing–two years after his work began. This information
gap is incompatible with adequate case management support and can be remedied by
allowing much more direct contact with the family.
ADEQUACY OF FAMILY SUPPORTS There are no family supports. Nurses, qualified
nurses, need to be obtained immediately, whether the family lives in
or
Guadalajara. Due to the prevalence of nursing and home health agencies in
Guadalajara with which this planner has worked, this planner’s preference is for a move,
for the family’s benefit as well as Case Manager
Greater proliferation of bilingual medical staff, a fact of life in Guadalajara, will make securing qualified staff
easier, but will allow him to move more rapidly to secure now absent medicines and
devices prescribed for Senor
APPROPRIATENESS AND SUFFICIENCY OF SUPPLIES, PRESCRIPTION
MEDICATIONS, LABORATORY TESTS AND DIAGNOSTIC WORKUPS A list of all
supplies, equipment, durable medical goods, and other items required by persons with
no limited ability to respond to their environment, is included in the Life Care Plan that
appears in the next section.
UTILITY OF CURRENT DURABLE MEDICAL GOODS, WHEELED MOBILITY, AND
TRANSFER DEVICES The durable medical goods purchased to date are inappropriate
to the family’s needs and certainly inappropriate to their locale. Detailed within the
architectural and wheeled mobility recommendations are the names of specific devices
and home access features that will make caring for Senor
much simpler.
CONTINUITY OF CASE MANAGEMENT SUPPORTS Continuity is a level of support
not characterized by abrupt or unexplained changes in the frequency and pattern of
case management contact. Having said that, there can be no continuity of case
management support unless the case manager is permitted–either by the insurer or
mandated to do so by the Industrial Commission–to set and maintain--a predictable
level of contact sufficient to obtain the resources Senor
needs without sudden
and inexplicable absences from the family. For the first twenty-four months, until a
home, physician and nursing care, equipment and adapted transportation are achieved,
family and provider contacts will be significantly higher than in later years. The contact
Senor Carmelo
Page 38
must be frequent, at least once per month, and given the lack of meaningful service
progress to date, an intensive model of face-to-face service is required. Due to Senor
Carmelo
changing needs and the multiple variables involved in service
delivery, a model of telephonic case management will not suffice, nor will a
geographically distant model of contact.
In this circumstance, a complex set of services needs to be quickly secured, coupled
with all the difficulties inherent in securing, orchestrating and carefully monitoring
nursing providers. Place into this mix, the fact that Senior Senor
will strongly
desire participation and a voice in how services are delivered (as well as attempt to
direct them to some degree) and a multi-faceted situation requiring active management
is created. Actions required to set up secure payment systems for vendors will be an
additional task to coordinate. Added to all of these factors are the complexities–for
either geographic location selected--of supervising Mexican housing contractors with
sufficient closeness that the desired result for Senor
is achieved, whether the
accessible housing is built, or rented and then renovated. Once a service delivery
structure is created which proves to work–verified by repeated on-site checks by the
case manager–then the level of service can be reduced until the death of the Senior
Senor
occasions a new set of variables for management.
Senor Carmelo
Page 39
VI
SECTION SIX
SENOR CARMELO
RECOMMENDED RESOURCES
The next pages portray resources required by Senor Carmelo
The Cost
Charts will provide the name of the resource, its characteristics and purpose, a
representative vendor, and the start and stop date of the resource. Charts are
presented in “portrait” mode for easier reading.
Senor Carmelo
Page 40
Life Care Plan for Señor Carmelo
Lifetime Resources Required
Architectural Renovation
Resource
Purpose
Provider
Start & End
Date
Frequency
Relocation Costs
Regardless of where a new dwelling for the
family is located, relocation costs for
the family will be incurred.
Provider to be iden ified when
needed.
2003
This resource may
need to be
repeated if a move
becomes
necessary.
Suitable accessible housing
for Señor
A suitable home should be built or rented for
the
family. To to facilitate he proper
care, safety and good health of Carmelo
he home must have certain
characteristics. These characteristics are
described below.
Local provider to be identified
2003
This resource may
need to be
repeated if a move
becomes
necessary.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
The home should provide sufficient space for family members will be living with Señor
this would require a minimum of 1,000 to 1,200
square feet (approximately 100 to 112 square meters) of living space.
The home should have at least two bathrooms, one designed for wheelchair access. This bathroom should include a roll-in shower, sufficient
space for turning a wheelchair, and for a caregiver and Señor
to be in the bathroom at the same time. The bathroom should also have
sufficient storage space for specialized adaptive equipment.
The home should have purified hot and cold running water,
windows and doors with screens,
floors that are easy to keep clean and dust free,
a laundry area including a washing machine and clothes dryer,
adequate lighting throughout the home,
a telephone for emergencies and ongoing case management contacts.
A covered garage area should be attached to the home so that Señor
may transfer into his wheelchair accessible Van without exposure to
the elements.
All doors should be sized for easy wheelchair passage (0.9 m or greater).
All hallways and common areas should be of sufficient size to permit easy wheelchair passage without crowding. The home’s wheelchair users
require approximately 10 percent more space on average. This is because the wheelchair itself requires more turning radius, a minimum clear
circle of five feet (1 53 m) in each room. Without this turning radius the individual in the chair may only enter he room normally, but must then exit
in reverse. This turning radius also provides the individual in the wheelchair a comfortable place to be in each room that is not block other traffic.
Large areas outside of he home should also be paved for easy wheelchair access outside. Some of these outdoor areas should offer sufficient
shade to permit extended stays outside without risk of overheating. These areas should be paved to permit easy wheelchair travel. Some of hese
areas could provide natural shade from vegetation, other areas should be covered with awnings or other overhang for rain protection. Grades (or
vertical rises) should be no greater than 1:10 (one unit up for every 10 units forward).
The house should be built on one floor and should be built so that the home and surrounding paved terrain shall have no greater than a one-half
inch vertical rise for easy wheelchair access.
The home should be equipped with a backup generator of sufficient size to operate some lights, the oxygen generator and suction equipment
during times of power failure.
Senor Carmelo
Page 41
Medical Care/Supports
Resource
Purpose
Provider
Start & End
Date
Frequency
Internist
This individual will be the “gatekeeper” for
Señor
care. To monitor internal
status and to change G-tube and
tracheostomy tube twice per year.
The provider will be dependent
upon where Señor
is
living.
2003 through
Lifetime
Three Times per
Year and PRN
Neurology
To monitor the status of Señor
shunt.
upon where Señor
is
living.
2003 through
Lifetime
Once per Year
Neurosurgery
To revise Señor
required.
upon where Señor
is
living.
2003 through
Lifetime
PRN
Case Management
To integrate, secure, identify, support and
maintain all services, supplies and care
required by Señor
as the result of
his injury.
To be identified
2003 through
Lifetime
40 hours per Month
for the First Year
then 25 Hours per
Month.
VP
VP shunt as
Basic overview of the case manager’s job duties includes: recruit staff , orient staff, provide on-site training for all care givers, coordinate clinical training,
patient emergencies, coordinate inpatient admissions, develop monthly staff schedules and post, conduct bi-monthly team conferences to monitor services,
development of monthly staff schedules, staff replacement, coordinate and monitor all providers (medical, aide, and therapy), supplier contacts and ordering,
employee payroll coordination, coordinate payments for all supplies, services and equipment, meet with treaters to coordinate the plan of care, identify new
areas of need or changes in function, oversee construction and moves.
Senor Carmelo
Page 42
Medical Equipment
Resource
Purpose
Provider
Start & End
Date
Frequency
Portable Suction Machine
12 Volt Battery Operated
This will be used while traveling and has a
second backup during power outage
emergencies.
upon where Señor
is
living. Supplies will come from
various locations including the
United States, Guadalajara and
San Luis Potosi depending upon
availability.
2003 through
Lifetime
Every Five Years
Ambu-bag
This device is used for emergency
respiration.
upon where Señor
is
availability.
2003 through
Lifetime
Every Three Years
1 6' Foot Portable Ramp
This ramp will be carried in the Van to be
used for access.
upon where Señor
is
availability.
2003 through
Lifetime
Every 15 Years
1 10' Foot Portable Ramp
This ramp will be carried in the Van to be
used for access.
upon where Señor
is
availability.
2003 through
Lifetime
Every 15 Years
Alternating Pressure Relief
Air Mattress
This mattress is used to continuously relieve
pressure against the skin and prevent skin
breakdown.
EASE Seating Systems, Inc.
Eagle Advanced Systems
Engineering. Inc.
8716 Skyway
Paradise, CA 95969
2003 through
Lifetime
Every Five Years
Fully Electric Bed
W/Siderails
Señor
currently has an electric bed.
A fully automatic bed will provide greater
convenience for his caregivers when this
resource is replaced.
upon where Señor
is
availability.
2003 through
Lifetime
Every 10 Years
Mattress for the above
Electric Bed
To be used under the alternating pressure
relief air mattress topper.
upon where Señor
is
availability.
2003 through
Lifetime
Every Five Years
Water Purification System
Public water in Mexico is not potable.
Although bottled water is safe and readily
available, so many areas of infection still
exist, particularly for an individual like Señor
For instance, dishes would still be
washed in potentially infected water. These
infections could be easily passed to Señor
upon where Señor
is
availability.
2003 through
Lifetime
As Needed
Senor Carmelo
Page 43
Medical Equipment
Resource
Purpose
Provider
Start & End
Date
Frequency
Maintenance for Water
Purification System
Filters and UV lamps will need to be replaced
periodically.
upon where Señor
is
availability.
2003 through
Lifetime
Approximately
Every Six Months
Hoyer Lift
Señor
currently has a Hoyer lift.
This one will be a replacement. Once the
overhead and ceiling lift is in place, the Hoyer
lift will become a backup.
upon where Señor
is
availability.
2003 through
Lifetime
Every 15 Years
Sling for Hoyer Lift
For safety this sling should be replaced
approximately every two years or as it begins
to show wear.
upon where Señor
is
availability.
2003 through
Lifetime
Every Four Years
Overhead Ceiling Lift
This ceiling lift will provide greater lift in
support for Señor
caregivers
reducing the possibility of injury.
upon where Señor
is
availability.
2003 through
Lifetime
Every Eight Years
Sling for Overhead Ceiling
Lift
For safety this sling should be replaced
approximately every two years or as it begins
to show wear.
upon where Señor
is
availability.
2003 through
Lifetime
Two Every Two
Years
Nebulizer
This nebulizer is used to provide breathing
treatments that will help break up secretions
in Señor
lungs so that a suction
machine may remove them.
upon where Señor
is
availability.
2003 through
Lifetime
Every Two Years
Stationary Suction Machine
(Suchco) and Supplies
This suc ion machine will be used on a dayto-day basis to provide proper tracheostomy
care and support airway integrity.
upon where Señor
is
availability.
2003 through
Lifetime
Every Two Years
Over Bed Tables (2)
These tables will be used to hold supplies
and other items for the convenience of
caregivers while attending to Señor
needs.
upon where Señor
is
availability.
2003 through
Lifetime
Every Four Years
Senor Carmelo
Page 44
Medical Equipment
Resource
Purpose
Provider
Start & End
Date
Frequency
Emergency Power
Generator
Since Señor
has a tracheostomy
and requires periodic suc ioning, it is
possible that a power failure would interfere
with his proper care and could even be lifethreatening.
upon where Señor
is
availability.
2003 through
Lifetime
Replaced Every
Five Years As
Needed
Bolsters for Positioning
These bolsters will assist Señor
caregivers and positioning him in bed for
procedures and pressure relief. Although
commercial bolsters are not available in
Mexico, similar bolsters can be fabricated
readily by local craftsmen.
upon where Señor
is
United States, Guadalajara, San
Luis Potosi depending upon
availability.
2003 through
Lifetime
Every Five Years
HEPA Air Filter
This filter will be used in Señor
bedroom to reduce the airborne dust
par icles.
upon where Señor
is
availability.
2003 through
Lifetime
Every 10 Years
HEPA Air Filter – filter
replacement
The HEPA filter will need to be replaced
approximately every year as needed.
upon where Señor
is
availability.
2003 through
Lifetime
Annually
Fax Machine, paper and
supplies
This machine will be used to both send and
receive information related to Señor
care.
upon where Señor
is
availability.
2003 through
Lifetime
Every Four Years
Clo hes Washer and Dryer
(including a stipend to pay
for electricity and gas used)
These machines should be provided to
reduce the workload of caregivers and to
increase the sanitation of all articles that
require washing.
upon where Señor
is
availability.
2003 through
Lifetime
Every Eight Years
Reclining RollIn Shower
Chair with Lap and Chest
Restraints
This chair will be used to shower Señor
in the roll in shower described in the
architectural renovation section.
upon where Señor
is
availability.
2003 through
Lifetime
Every Eight Years
Senor Carmelo
Page 45
Medical Supplies
Resource
Purpose
Provider
Start & End
Date
Frequency
4 Bottles Hydrogen
Peroxide 16 Oz.
To be used during suction.
upon where Señor
is
availability.
2003 through
Lifetime
Monthly
15 Bottles Normal Saline
1000cc
To be used during suctioning, wi h the
nebulizer and for other purposes.
upon where Señor
is
availability.
2003 through
Lifetime
Monthly
1 Box 2 X 2 Sterile Gauze
Pad
For general sterile wiping and bandaging.
upon where Señor
is
availability.
2003 through
Lifetime
Every Two Months
1 Box 4 X 4 Sterile Gauze
Pad
For general sterile wiping and bandaging.
upon where Señor
is
availability.
2003 through
Lifetime
Monthly
2 Bottles Sterile Water
For use wi h trach and Foley catheters.
upon where Señor
is
availability.
2003 through
Lifetime
Monthly
2 Rolls 1" Plastic Micropore
Tape
For general bandaging and placement of
tubing and other items.
upon where Señor
is
availability.
2003 through
Lifetime
Monthly
2 Trach Kits per Year
To replace the existing trach tube.
upon where Señor
is
availability.
2003 through
Lifetime
Every Six Months
3 Cases Adult Diapers,
Large (60 per Case)
To address bowel incontinence.
upon where Señor
is
availability.
2003 through
Lifetime
Monthly
Senor Carmelo
Page 46
Medical Supplies
Resource
Purpose
Provider
Start & End
Date
Frequency
1 Box Bed Pads
To preserve bed linens due to incon inence.
upon where Señor
is
availability.
2003 through
Lifetime
Monthly
1 Box Alcohol Swabs
For general sterile cleaning and prior to
injections.
upon where Señor
is
availability.
2003 through
Lifetime
Monthly
Lambskin Boots (2 Pair per
Year)
To reduce the probability of skin breakdown.
upon where Señor
is
availability.
2003 through
Lifetime
Every Six Months
Lambskin Elbow Protectors
(2 Pair per Year)
To reduce the probability of skin breakdown.
upon where Señor
is
availability.
2003 through
Lifetime
Every Six Months
Hand Splints (1 per Year)
To reduce contractures in the hand as
prescribed by The Institute for Rehabilitation
and Research.
upon where Señor
is
availability.
2003 through
Lifetime
Annually
2 Boxes Clean Gloves
For general procedures such as peri care
and bathing.
upon where Señor
is
availability.
2003 through
Lifetime
Monthly
1 Box Sterile Gloves
For sterile procedures such as suctioning.
upon where Señor
is
availability.
2003 through
Lifetime
Monthly
Suction Canisters, Tubing,
and Filters as Needed (2
per Month)
Supplies to be used with suction machines.
upon where Señor
is
availability.
2003 through
Lifetime
Monthly
Senor Carmelo
Page 47
Medical Supplies
Resource
Purpose
Provider
Start & End
Date
Frequency
2 Cases 12 Inch French
Suction Catheters with
Sterile Cup and Glove
Supplies to be used with suction machines.
upon where Señor
is
availability.
2003 through
Lifetime
Monthly
1 Box Sterile Cotton Tipped
Applicators
For careful cleaning around G-tube and
tracheostomy site.
upon where Señor
is
availability.
2003 through
Lifetime
Monthly
4 Rolls 1" Cloth Tape
For securing tubes and other items as well as
bandages.
upon where Señor
is
availability.
2003 through
Lifetime
Monthly
Germ Free Soap (12 Bottles
per Year)
For general cleaning of Señor
well as for hand washing for staff.
upon where Señor
is
availability.
2003 through
Lifetime
Annually
Foley Catheter Silicon
Coated 28 Fr. 5 cc/ml and
Related Supplies
Señor
uses these catheters for
feeding into an incision in his abdomen.
upon where Señor
is
availability.
2003 through
Lifetime
Monthly
Portable Oxygen Tank for
Traveling with Supplies
It is standard practice to maintain standby
and oxygen for anyone who is airway
compromised like Señor
upon where Señor
is
availability.
2003 through
Lifetime
PRN
1853 Hydrotherm Heat and
Moisture Exchanger with
Supplies
This device helps to prevent dehydration due
to the moisture in expired air.
upon where Señor
is
availability.
2003 through
Lifetime
One per Week
Liquid Formula for Adults
such as Jevity Plus
This liquid nutri ion will be used for bolus
feedings of Señor
sense after his
injury he cannot consume anything orally.
Currently, he
family fabricates heir
own formula from a mixture of chicken, Caro
syrup, corn oil and other ingredients. There
may be significant nutritional issues wi h this
homemade formula as well as problems with
clogging he G-tube.
upon where Señor
is
various locations including he
availability.
2003 through
Lifetime
One Case per
Month
His nutritional needs are
1800 to 1900 kcals, 65 g
protein and 2400 cc fluids
per day.
Senor Carmelo
Page 48
as
Medical Supplies
Resource
Purpose
Provider
Start & End
Date
Frequency
TED Hose
Needed to maintain blood pressure and
reduce edema when out of bed.
upon where Señor
is
availability.
2003 through
Lifetime
Four Pair per Year
Portex/Shiley #6 Trach
Tube
Señor
has an active tracheostomy.
This facilitates airway integrity and permits
removal of secretions. Occasionally, this
tube must be changed.
upon where Señor
is
availability.
2003 through
Lifetime
Every Three
Months
G-Tube
Señor
can no longer eat or drink by
mouth. All food and liquids must be
introduced through this G tube.
upon where Señor
is
availability.
2003 through
Lifetime
Every Six Months
Senor Carmelo
Page 49
Home Care
Resource
Purpose
Provider
Start & End
Date
Frequency
Nursing Care/Home Health
Aide
To provide ongoing care for Señor
onto the direct supervision of the
family.
upon where Señor
is
living.
2003 through
Lifetime
This resource is
required 24 hours
per day, seven
days per week, 365
days per year.
Basic overview of Care Performed by Nursing Staff:
Tracheostomy Care x 2
Vital Signs x 6
Suctioning x 5 - 6
Pulmonary Treatments x 2
Medication Administration x 6
Bowel Care x 1
Bladder Care x 4
Case Charting (each shift)
Passive Range of Motion activities to decrease contractures
Peri-Care/other hygiene
Wound care
Transfer to bed from chair and vice-versa
Bolus Feeding
Laundry and Cleaning
Cleaning equipment
Trash removal
Assistance w/equipment
Senor Carmelo
Page 50
Hospitalizations
Resource
Purpose
Provider
Start & End
Date
Frequency
Periodic Hospitalizations
These are likely to be emergency, healthrelated hospitalizations for issues like
pneumonia.
upon where Señor
is
living.
2003 through
Lifetime
PRN
Included in this category would be hospitalizations that may take place in the United States and may require air ambulance service due to the severity of the
health issue. At least one member of Señor
family would travel with him and stay throughout his term in he hospital. Their expenses for food lodging
and transportation would also be included within this category.
Senor Carmelo
Page 51
Medications
Resource
Purpose
Provider
Start & End
Date
Frequency
An ibiotics
An assortment of antibiotics will be needed
by Señor
to address infection.
upon where Señor
is
living.
2003 through
Lifetime
PRN
Other Medications As
Needed
Señor
was released on baclofen and
a number of o her medications from The
Institute for Rehabilitation and Research.
These medications include: albuterol sulfate,
amantadine HCI syrup,bisacodyl and
lansoprazol. Is likely, given his condition that
he will require these medications or others in
the future depending upon condition.
upon where Señor
is
living.
2003 through
Lifetime
PRN
Senor Carmelo
Page 52
Projected Evaluations
Resource
Purpose
Provider
Start & End
Date
Frequency
Inpatient Full Medical
Workup
Inpatient hospital visit to establish medical
baseline and develop a local plan of care for
Señor
Hospital San Javier
Avenida Pablo Casals # 640
Colonia Prados Providencia,
C.P.44670
Guadalajara, Jalisco, México
2003 through
Lifetime
One Time Only
Then PRN
Wheelchair Seating
Evaluation
This evaluation should be performed
periodically as new wheelchairs are
purchased. The initial evaluation could be
performed at hospital San Javier during the
inpatient full medical workup.
Please see the above provider.
2003 through
Lifetime
Every Four to Five
Years
Travel Expenses
These travel expenses include meals and
lodging. They will be incurred by the
family to accompany Señor Carmelo
on these evaluations.
Various providers as needed
2003 through
Lifetime
As Needed
Various Lab Tests
These lab tests include: CBC, Chem panels,
pyelogram, chest x-rays , MRI, CT scans. All
of these tests would be dictated by symptoms
and would be performed PRN.
Various providers as needed
2003 through
Lifetime
PRN
Senor Carmelo
Page 53
Adapted Transportation Resources
Resource
Purpose
Provider
Start & End
Date
Frequency
Ford Windstar Wheelchair
Accessible Van
This Van will provide Señor
with
access to the community and transportation
for emergency and ongoing medical care. A
high-quality, rear entry ramp equipped Ford
Windstar Van well-suited for Señor
more reliable than a lift equipped van and
readily serviced in Mexico is recommended.
Liberty Motor Company
2390 South Service Rd. West,
Oakville, ON L6L 5M9
(This Van would have to be
shipped from Ontario to Señor
loca ion in Mexico.
The quality of this Van and the
reasonable price make this
worth the additional trouble.)
2003 through
Lifetime
Every Five Years
Fuel, Insurance and
Maintenance for the above
Van
This item would cover the costs for he
ongoing use, upkeep and security of this
vehicle.
Various suppliers as needed
2003 through
Lifetime
Annually
Senor Carmelo
Page 54
Wheelchairs and Mobility
Resource
Purpose
Provider
Start & End
Date
Frequency
Manual Solara Wheelchair
with Specialized Seating
and Positioning Equipment
This is he wheelchair that was prescribed by
The Institute for Rehabilitation and Research.
Periodic evaluations for recommendations for
this chair should be provided – at
approximately four-year intervals
Invacare
(Invacare has offices in Mexico
that may be able to supply this
wheelchair. Otherwise, the
chair will need to be brought
from the United States.)
2003 through
Lifetime
Every Four Years
All-terrain Wheelchair with
Specialized Seating and
Positioning Equipment
This chair would provide señor
with
increased community access since large
parts of Mexico remain inaccessible to
standard wheelchairs.
Access to Recreation
8 Sandra Court
Newbury Park, CA 91320
2003 through
Lifetime
Every Four Years
Wheelchairs and Mobility Maintenance
Resource
Purpose
Provider
Start & End
Date
Frequency
Ongoing Maintenance for
the above Wheelchairs
Conditions in Mexico will cause these
wheelchairs to require more han the usual
frequency of repair.
upon where Señor
is
living.
2003 through
Lifetime
Annually
Senor Carmelo
Page 55
VII
SECTION SEVEN
SENOR CARMELO
RECOMMENDED REQUIREMENTS FOR LEGAL OVERSIGHT
C H A R A C T E R I S T I C S OF AN IMPLEMENTATION STRUCTURE AND CASE
MANAGEMENT FUNCTION FOR SENOR CARMELO
Attempts to provide Senor
with services have been ambiguous, inconclusive and uncertain from 1998 to the
present.
A WORKABLE MODEL OF CASE MANAGEMENT For a case manager to have any
effectiveness in the future in coordinating resources, the function needs to reside within one
location, with one identifiable person accountable to the Industrial Commission and accessible
by the
family. Several features mark effective performance of an effective case
management function. They are:
1.
Working knowledge and “hands-on” experience in selection, purchase and
adaption of equipment and other durable medical goods for effective use in the
geographic context in which the disabled individual resides, in this case, a rural
Mexican context. This combination of knowledge and “hands-on” experience in
equipment selection, adaptation, repair and use will preclude costly future
purchases of wheelchairs and lift devices incompatible with Senor
rural
environment
2.
Accountability for scheduling and delivering resources with sufficient timeliness
that care givers do not run out of prescribed medications and supplies, as has
been now the case
3.
Authority to ensure that vendor bills are paid with enough punctuality that
nurses or other providers do not resign, their bills
Senor Carmelo
Page 56
for service having failed to be paid, as is the case for the
working in May 2001 and paid by the father.
nurses’,
4.
Functional understanding of the resources required to secure rehabilitation goods
and services available in the context where the disabled individual resides, and,
the fiscal resources required to secure these services, e.g. home health care,
housing services, ambulance services, adapted transportation services, supplies,
prescriptions, and licensed nursing services
5.
Functional knowledge of the goods and services which are not
manufactured or produced in the geographic context where the disabilities
individual lives, resides, with concomitant capability to identify when goods
and services must be shipped from the United States to secure their
availability
6.
Working knowledge of Mexican pharmacies with automated inventories,
familiar with computers, with capability to produce accountable, detailed
bills to payors of services
7.
Familiarity with how to set up routine wire transfers of funds to Mexican
entities with sufficient regularity that vendors are compensated with thirty
days of services, not one hundred sixty days
8.
Sufficient financial Independence and autonomy from current payors of
service to ensure that services can be selected and delivered as the
needs of the patient dictate, i.e. service contacts, on-site visits, and
tangible services identified, chosen, purchased and secured with the
safety of the patient the predominate value, not the value of long-term cost
containment and revenue enhancement for payors.
CHARACTERISTICS OF IMPLEMENTATION STRUCTURE THAT ENSURES SERVICE
ACCOUNTABILITY To date, the service delivery environment for Senor
has not
been distinguished by ensuring that he has consistent access to prescribed services.
One argument that can be made is that primary efforts have focused on investigating and
locating a facility for patients with chronic care needs. Even with pursuit of this option,
researching potential long-term facility arrangements should not have precluded immediate
attention to the deplorable sanitary and living conditions to which Senor
has been
relegated 1998.
By September 2000 with initiation of case management services, appropriate secure, hygienic
rental property could have been secured for the family while investigations of other options
continued. Relocation to San Luis Potosi and rental of housing would have afforded Senor
Senor Carmelo
Page 57
with potable water, a roof that does not leak, telephone service, indoor plumbing, and
access to medical services and nursing care through one of the agencies listed in the San Luis
Potosi telephone book. Rental outlay for safe, accessible housing, utilizing the same locally
secured physician resources obtained in April 2001, would have cost approximately $23,800,
less than the $24,000.00 outlay made in January 2002 to fly Senor
by private jet to
and from Houston, Texas one year later.
Another argument that might be offered to justify why service delivery has not occurred since
1998 is that the payor wanted to review recommendations made by TIRR staff at the end of
the inpatient evaluation stay March 2002. Were this factor to account for the delay in moving
Senor
to acceptable housing, then all–not just one–of the recommendations made by
TIRR staff in March 2003 would have been implemented.1 To date, only one of the
recommendations in the March 1, 2003 staffing has been implemented–securing wheeled
mobility that is unusable on the rocky terrain outside of Senor
small cinder-block
house. Senor
primary needs are so clear as to stunning in their simplicity. He needs
a clean safe house with running water, a roof and consistent electricity, proximity to services,
and staffing that provides some respite for over-burdened, now exhausted, family members.
Further delay and denial of resources will continue unless strong legal intervention is brought
to bear on Senor
circumstances and the case manager involved is permitted to act
with the necessary freedom required to secure the services his training and background would
dictate. Appropriate legal intervention in this circumstance would not only mean acceptance of
the plan by the Industrial Commission, but would also proscribe many of the features used in
Consent Decrees to assure adequate progress toward much-needed service objectives for
disenfranchised individuals. This would include initiation of procedural safe-guards to
guarantee that services prescribed would be services provided, and, agreed-upon dates when
services will be in place.
During development of this care plan certain problems in service delivery to Senor
have emerged with great regularity. If there is continued lack of agreed-upon service
objectives between and among participants, there will continue to be–for the
family–lack of access to decent housing, telephone services, prescribed medications,
transportation, supplies, and much-needed nursing services. These conflicts about how
resources are to be expended, in both the clinical and research experience of this planner,
continue in perpetuity until legal and procedural safe-guards are instituted that serve to protect
1
MD in the March 1, 2003 TIRR Discharge staffing
apparently stated that the home environment was inappropriate but would
not seek to over-ride the father. His consistent recommendation made in
consultation June 2, 2003, was for the family to move and if a move could
result in greater access to services, he would support continued home
MD. Consultative Interview. TIRR,
placement.
Baylor College of Medicine, Houston, TX. June 2, 2003.
Senor Carmelo
Page 58
the interests of all parties involved and define the means through which the conflicts are
promptly identified and resolved.
For any case manager like Mr.
the process of providing services to the
family
cannot be anything but frustrating and discouraging–given the obvious needs for service that
are apparent in this situation. It can only be demoralizing for him to have his skills and training
so suborned by the payor’s financial interests that he is allowed one annual trip to Senor
fundamentally to confirm for the payor that Senor
has managed to survive
for another year in sub-standard living conditions–the same conditions assiduously maintained
and unmodified by the payor since 1998–conditions that would dictate immediate referral to
Adult Protective Services were Senor
in the United States.
No case manager will be able to orchestrate service delivery for the
family until, prior
to service initiation in Mexico, mandatory accord is reached between and among all
participants, under the strong aegis of the Industrial Commission. If the following
recommendations seem naive held against the usual operation of the Industrial Commission,
this writer apologizes for lack of direct experience working with the Commission. These
recommendations are best read in the spirit they are intended, that of seeking an end to a
service system for Carmelo
that is in no way working to his benefit. They are also
best viewed in light of the planner’s research and consultation experience in implementing
local, regional, and state-wide systems of accountable case management services in public
sector settings marked by conflict and acrimony:
1.
All parties involved will agree on service goals, objectives and outcomes
and must observably signify their understanding that these are the
services to be immediately secured for Senor
Services provided
will not be subject to dispute and will be those services contained in the
Life Care Plan mandated for development by the Court November 2000.
It is now indisputable–and agreed to by all physicians treating Senor
that the family must find it in their best interests to move to
greater geographic proximity to medical services. That is a first priority.
2.
Further, all parties involved must agree on the strategy and process to be
used with the Senior Senor
to accomplish this objective. This
objective is best accomplished by gradually demonstrating to the family
the benefits--to them and to their disabled family member--of such a
move. This cannot be accomplished by–as has been attempted in the
past–by fiat or directive, or investigations of placement alternatives
conducted without his knowledge, most notably research requested by
Senor
legal counsel requested on June 6, 2002. The
participation of the family must be secured on future actions toward an
objective of moving closer to medical services or it won’t be reached. A
first step towards this end is the recommended inpatient stay at San Javier
Senor Carmelo
Page 59
Hospital in Guadalajara to a) establish baseline functioning and b)
introduce Senor
to the geographic benefits of a move to an area
with higher concentrations of accessible medical care, and c) demonstrate
to Senor
that his son’s most credible treating physician, Dr.
supports this move.
3.
This objective is best reached by concretely demonstrating to Senor
Senior–the head of the family–the benefits of a geographic move,
to assure him that he is still in control of his family, and, that his daily
responsibilities will be lessened with such a move. Nothing will be gained
by continuing to present Senor
Senior with culturally incompatible
decision processes that do not involve him or treat him with less than the
dignity and respect he requires.
4.
In order for Senor
Senior to countenance this decision, the Case
Manager working with him must be able to tangibly demonstrate that he
can influence circumstances–otherwise, Senor
Senior will not
regard him as valuable. Greater family accruing to the family must
accompany his presence.
5.
Logically, Mr.
as case manager, must be granted far greater authority
to be the person who works in concert with the
family,
responsible for identifying, locating, securing, keeping, and evaluating all
prescribed resources for the
family. Mr.
must be given the
authority he needs immediately to actively manage this case, with
sufficient leeway to travel as needed, to plan as needed, and granted the
responsibility to set up service accounts with all vendors, guarantee the
means of payment, and change vendors if vendor services are deemed
inappropriate, too costly, or place Senor
at risk.
6.
Sixth, all parties must agree that resources required by Senor
are
those he needs in order to sustain life; they must be made available to
Senor
within time-frames specified in the Care Plan in order to be
effective, and they must not be debated after service inception.
7.
Vendors will be selected for their capability to provide bi-lingual, costeffective, accountable, timely services to the
family. A list of
designated vendors will be provided both to the Industrial Commission and
to the payor. Vendors will be selected for their capability to have
automated inventories, computerized bill generation capacity, and bilingual capability. They will submit bills to the Industrial Commission and
these bills will be approved for payment. With approval, sufficient funds to
pay one-half of the funds required for one year of service with an
appropriate bi-lingual banking entity will be placed with that entity and the
Senor Carmelo
Page 60
approved list of vendors provided to the banking entity. The Industrial
Commission will pre-approve payment for all bills that are part of the Care
Plan for Senor
and payment to service vendors can then occur
within 30 days in order for Senor
to have on-going access to the
resources prescribed for him. When, after provision of a service, vendor
attempts to secure financial reimbursement are met with ambiguity, delay,
or resistance by the payor, the Industrial Commission will be notified
immediately.
8.
If, by history, bill-paying has been less than prompt, procedural safe-guards will
be established and observed to prevent abrupt and unexplained discontinuities in
service.
9.
The Case Manager will be responsible for informing the Industrial
Commission if vendor bills are not paid within 30 days of receipt of the bill,
or, sufficient funds to pay agreed-upon expenses have not been placed in
accounts for bill-paying purposes.
10.
The Case Manager must be granted accountability and responsibility for
updating the Care Plan every twelve months, noting changes in
circumstances, health status, and family composition. Any changes
directly–and negatively–affecting Senor
must be immediately
noted and directed to the proper entities within one week.
11.
Sufficient funds to pay for six months worth of anticipated bills–agreed to
in advance by all parties–must be placed in an interest-bearing account
with a reputable Mexican banking entity with bilingual staff.
12.
The Case Manager must be responsible for setting up all methods for
financial reimbursement for vendors, for setting up methods of routine wire
transfer, and, accountable for ensuring that the entity selected to receive
funds from the US will have a list of designated accounts that will be paid
monthly, e.g. electricity, telephone, gas, water, Trust fees if a house is
bought, rental fees if a house is rented for the family, nursing, ambulance,
physician, supply, and pharmacy bills, for example. The Mexican entity,
e.g. Lloyds Trust, Banamx, Bancomer, paying bills for the payor will
require that each vendor submit monthly invoices that detail all services
provided by date, content, and amount. The Mexican entity will set up
means to provide monthly copies of all bills paid and proof of date paid to
the payor.
13.
Site visits are strongly recommended to be completed by the payor once
per year to receive assurances that funds are being used for the
designated purpose.
Senor Carmelo
Page 61
14.
As much as possible, financial transactions must occur between vendors,
the Industrial Commission, the payor, and the local banking entity.
Because all vendor relationships will be known, Senor
Senior will
have no role in subsidizing services or paying vendors out of pocket. In
this way, service accountability can be maintained for the payor.
Senor Carmelo
Page 62
#2
Ms. Maria
Preliminary Report for July 24, 2008 Mediation
Life Care Plan Services, Preliminary Cost Estimates
and Foundation for Costs
Prepared For
Sr. Claims Consultant, Workers' Compensation
By
Penelope Caragonne, Ph.D.
79 Calle Hidalgo
Ajijic, Jalisco, MX 45920
Ms. Maria
Life Care Plan Services, Preliminary Cost Estimates
and Foundation for Costs
Introduction The request for a Life Care Plan was received in late March 2008. At point of
referral, the referral source–Ms.
was notified that due to previous commitments,
data collection on the plan would begin April 28, 2008. Preliminary work completed prior to April
28, 2008 included file review of materials sent, review of paid receipts, and collection of
information on the size, terrain, and scope of resources in the town in which Ms.
resided (3 hours).
Constraints to Completion of Work Data collection initiated April 28, 2008 and proceeded for
five (5) hours. This work, plus the initial file review, encompassed eight (8) hours. This work
resulted in initial contacts with several local providers of supplies and drugs, creation of a
spread sheet of categories which was to be filled as data were collected, drafting of an
introductory letter to Ms.
stating the scope of my work, and contact with
to request Ms.
telephone number to set up an initial telephone
conference.
I contacted Ms.
at
on April 29, 2008 to request permission to
make contact with Ms.
This email was forwarded to Annette
on that date.
On May 6, 2008, contact was received from Ms.
stating that a motion had been filed
by Steven
and I would be contacted by Ms. Pat
when it was possible to contact
Ms.
I was advised to cease work until I had received permission from Ms.
Work ceased on May 6, 2008.
Having no contact from
in May and June, an email was sent to
on June 23, 2008 asking if I should proceed with the work or close my file. I received
an email from Ms.
on June 23, 2008 stating that Mr.
motion had been
dismissed and work could resume. Annette
and I made contact by June 26, 2008 to
discuss the scope of work.
July 24, 2008 Mediation I was informed by Ms.
that a mediation was scheduled for
less than one month away--July 24, 2008. Ms.
asked if I could complete preliminary
figures by the date of the mediation, given the time frame. I agreed that I would attempt to
produce a preliminary cost report by that date. I could not commit to additional research as I
had long-standing plans involving facility placement of a family member with Altzheimers.
Additional work to collect data for the plan was, however, completed during the process for this
placement.
The original Life Care Plan completion date was scheduled for August 2008. On June 26,2008
(Thursday) when I agreed to produce the preliminary cost estimate, contact had not been
scheduled with Ms.
Full data collection could not begin until she could schedule a
Ms. Maria
Services, Resources and Preliminary Costs
Page 1
time to meet with me by telephone and I had opportunity to talk to her regarding her needs and
long-term plans.
From June 27, 2008 to July 2, I completed work on an existing file. An introductory email was
sent to Ms.
on July 3, 2008 (with copies to Ms.
attorney and
The email requested a conference call to review her needs and identify access
barriers in her living and community environment. Previous to that call, a copy of a work
estimate from a local architect was received from
requesting review of the
costs. Ms.
requested that I review the appropriateness of the estimate. This estimate
was for completion of a stand-alone bedroom with plumbing was reviewed. No comments could
be made, however, until pictures of the completed work were received from Ms.
against which to balance the estimate and the quality of the completed work.
Ms.
responded to my introductory email stating July 7, 2008, 3:00 PM was convenient
for a conference call. Preliminary work to prepare for the call and the actual conference call
was completed on July 7, 2008. Beyond the data collected in the telephone call, the following
was requested from Ms.
C
C
C
C
C
C
Detailed exterior pictures of the completed architectural modifications
Detailed interior pictures of the completed architectural modifications
Pictures of the 19 year old auto used for transport and community activities
Pictures of all of her equipment
Pictures of the family members (showing height and age) who are responsible
for folding her wheelchair and placing it in the back seat of the auto, but also,
Responsible for pushing her up and down the hills when she is out in the hilly
terrain of Arequippa.
sent two files of receipts prior to July 16, 2008. On July 16, 2008, Ms.
provided the materials I requested. A series of PDF files were also received from
on the same date containing copies of receipts sent to
by Ms.
for the past several months. An aspect of the email received from Annette
again confirmed that the Life Care Plan Costs needed for mediation need only be preliminary in
nature. Given the time constraints under which this work proceeded, the material to follow is to
be considered in preliminary form. More precise costs can be determined upon further
investigation and with additional time.
If needed, future data collection will proceed with requests for cost estimates and interviews
with physicians. These costs will be included in a final Life Care Report with narrative and
typically formatted Cost Charts. Some items will be expanded; some items changed. For
example, there are no wheelchair dealers in Peru who sell the type of wheelchair Ms.
uses. Invacare has an outlet in Bolivia, the closest country to Peru.
Replacements wheelchairs and parts will need to be secured in either Bolivia, Colombia or from
the United States. Secondly, hand controls for a new car for Ms.
are being added to
the Preliminary Cost Report. The family car owned by the
is 19 years old (see
picture) and has a stick shift. If she is to learn how to independently drive before her parents’
Ms. Maria
Page 2
demise, her disability will require not only that the family secure a newer, safer car with an
automatic transmission, but also, replace her current non-folding wheelchair with a Titanium
folding wheelchair she can lift into the car independently. Architectural modifications already
completed provide Ms.
access only to one-third of her house. While the modifications
are superb, they only allow her parents to visit her if they come down to her bedroom. This is
not a feasible arrangement. For this reason, two stair lifts are recommended for addition to the
architecture of Ms.
home. These stair lifts will permit her to transfer to the second
floor and join her family upstairs. Relative to those items to be shipped in from other countries,
shipping costs will be estimated. Ms.
was also contacted to obtain the shipping costs
on the standing frame.
Given the very shortened time frame for completion of this work, cost totals
across each resource area–physician visits, therapeutic services, wheelchairs,
etc--will be conveyed in the form of a one-page Summary Cost Chart.
The chart will have three columns–the first column will list all categories in a Life Care Plan; the
second column will list the total average yearly costs of all items within that category, with an
Endnotes section showing the rationale or foundation for each item. The third column will
summarize all One-Time Only Costs by category. In the final Life Care Plan report, operational
descriptions for the purpose and use of each service will be provided, as well as a
representative provider from which each service can be secured.
Should a request for completion of a full Life Care Plan be received after
mediation on July 24, 2008, I will be able to complete this work upon receipt of a
written request with an eight week time frame, given other pending work
commitments.
Ms. Maria
Page 3
MARIA
PRELIMINARY COST ESTIMATES
ESTIMATED COSTS
WITHIN EACH LIFE CARE PLAN CATEGORY,
PURPOSE FOR ITEMS,
AND, FOUNDATION FOR ESTIMATED COSTS SHOWN
Ms. Maria
Page 4
NOTES FOR COST CHARTS
1.
Physician Care PM&R and/or Neurology Maria now currently receives care
predominantly from a neurologist in Peru. In the United States, she received care from a
physician specifically trained in Physical Medicine and Rehabilitation, Ann
MD.
This discipline should be added to her on-going care as well as three other specialities.
Gynecology Because Ms.
is paralyzed from the waist down, she would have
difficulties identifying problems within her urinary tract and bowel area due to lack of
sensation (urinary tract infections, etc). As well, her medical examinations are likely to
be more lengthy as a physician will require more time to conduct an examination. Ms.
cannot report on symptoms requiring sensation to perceive and will require
more extensive time by a qualified physician. Moreover, in Latin countries, examining
tables are not modified to raise or lower their height for ease of physical examinations as
now found in some specialists’ offices in the United States. Four instances per year of
contacts with th neurologist, urologist, gynecologist, and PM & R physician are
recommended.
Urology General physician/urology to monitor Ms.
for health concerns and for
the high potential of urinary tract infections related to her spinal cord injury. In addition,
in the Supplies section of this report, an antiseptic is added to assist her in sterilizing
her catheter on a daily basis (2 times per year lifetime).
C
2.
Total specialties: Gynecology, PM and R, neurology, and urology
lifetime (2 x per year lifetime each).
Therapeutic Services Maria has been diagnosed with depression attendant to her
spinal cord injury. Despite her very positive attitude and enthusiasm, she will no doubt
experience periods of depression as she transitions through different stages of her life
and/or encounters obstacles–emotional, vocational, independent living, or architectural.
Following are typical stages in which she might experience depression or anxiety: death
or illness of her parents, now her primary source of support; attempts and desires to
beginning dating; marriage, like most young women her age; greater emancipation from
her parents; efforts to be independent in local community; stigmatization from former
friends and acquaintances; employment searches in Peru after she graduates with her
on-line teaching degree; and, return to the inaccessible Peruvian University campus so
she can finish the degree in industrial engineering started before she emigrated to the
United States.
Adjustment counseling of sufficient duration is recommended to ensure treatment of
acute depression (2 x per week 16 weeks x 1instance lifetime = 32 instances) and
treatment during the maintenance stages of depression (4 times per month for 24
Ms. Maria
Page 5
months lifetime = 96 visits lifetime) to ensure greater self-confidence, greater
assertiveness, and treat depressive disorder, and, anxiety as they occur. It is wellknown that untreated depression is far more damaging to a health state than chronic
illness, is significantly under-treated, and, has significant effects of mortality and
morbidity (Depression Guideline Panel. Depression in Primary Care: Volume 1.
Detection and Diagnosis. Clinical Practice Guideline, Number 5. Rockville, MD. U.S.
Department of Health and Human Services, Public Health Service, Agency for Health
Care Policy and Research. AHCPR Publication No. 93-055 0. April 1993. ) It is also wellknown that few people receive treatment for depression of sufficient length to remediate
both acute and maintenance stages of depression (Chatterjim S. Depression, Chronic
Diseases and Decrements in Health: Results form the World Health Surveys. Lancet.
2007 Sep 8;370(9590): 851-858). In general, perceived health and quality of life for
persons with spinal cord injury were related. Over all, those who reported generally good
health also tended to score higher on the various measures of perceived quality of life,
life satisfaction, and well-being, and, more importantly for this recommendation, they
generally scored lower on measures of perceived stress and depression (Wood, V.,
Wylie, M.L., & Sheafor, B. (1969). An analysis of a short self-report measure of life
satisfaction: correlation with rater judgments, Journal of Gerontology, 24(4), 465469).
Physical Therapy recommended in the Life Care Plan (
BSN, RN, CLCP in
collaboration with Vivien
MD), at a level of 4 visits every 5 years for 16 refresher
courses of physical therapy throughout her life expectancy of 81 years (16.2 times
lifetime at 4 instances per time), plus an initial evaluation immediately of four instances.
Services could include custom seating evaluations and improvement of shoulder pain, if
present; treatment for shoulder pain, and, identification of period to move to a power
wheelchair due to “shoulder over-use,” treatment for complications of accelerated aging
with a spinal cord injury (transfer techniques, shoulder conservation) and treatment
when older of the signs and symptoms of decreased physical dependence (e.g.
increases in amount of care needed on a daily basis to ensure independence, postural
complications, weight gain, and fatigue). It is recognized that licensed therapists may
not be available in Arequippa at this time and that rehabilitation services may need to be
secured from the local hospital in Arequippa with a request that they be provided in the
home.
An occupational therapist or rehabilitation technologist is also recommended to operate in
tandem with the physical therapist to conduct home visits with the physical therapist to
utilize skills related to her discipline, with an emphasis on access needs. Both will
provide services in Ms.
home and community environment to observe Ms.
more comprehensively. The scope of work for these therapists will include an
initial wheelchair seating and positioning evaluation for the new folding wheelchair with
follow-ups as needed and upon the purchase of any new wheelchair. The therapists will
also review needs for assistive technology, driving needs, review auto access and
transfers, wheelchair placement in auto, review of architectural access needs, job-site
accommodations, evaluation of needs for strengthening and exercise regimen, review of
basic nutritional needs, etc. These therapists will act as the gate-keeper for all technology
related needs that Ms.
may have. This will assure that all recommendations for
Ms. Maria
Page 6
equipment coordinate both with Ms.
needs and with the other equipment that
she uses. The time for these individual is a shown as a new evaluation immediately of
four visits each, then an additional set of visits lifetime.
Nurse/Case Manager: A nurse/case manager is recommended for purchase at the
following frequency: (Year 1 to life: 10 hours per year). These hours can be used in larger
aggregates per year during periods when Ms.
is shipping new items to Peru
from Bolivia, Colombia, or the United States, identifying local and out-of-country
resources for new items, handling a specific medical problem, coordinating her care
needs with a range of providers, arranging out of Arequippa trips for examinations, etc).
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3.
Counselor for Depression (128 visits times lifetime)
Physical Therapist (17 times x 4 instances per time)
Occupational Therapist (17 times x 4 instances per time)
Nurse Case Manager (10 hours per year)
Diagnostic Tests and Vaccinations The range of medical evaluations typically
recommended for persons with low-level spinal cord injury are included until a final
consultation is obtained with Ms.
neurologist. Costs are included for:
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Renal ultrasound with IVP (annually for life)
Blood Urea Nitrogen (BUN) and Creatinine Clearance (annually for life)
Urodynamic Complex Cystometrogram (CMG with voiding pressure
studies (2 studies lifetime);
Cystourethrogram xray to R/O (rule out) ureter reflex (3 x lifetime);
Urine culture and sensitivity (2 x year);
Urinalysis (2 x per year);
Complete metabolic panel (2 x per year),
Complete blood count (2 x per year);
Influenza shot (1 x year);
Pneumonia vaccine (1 x year);
Lipid panel (1 x per year);
Thoracic x-rays (1 set of four every 15 years); and,
DXA-scan (1 x per year to monitor extent of bone loss due to high risk
of early osteoporosis).
Vaccinations for cholera, malaria, Hepatitis A, chagas, and typhoid (1 per
year for life per shot x 5 shots).
Due to range of infectious diseases prevalent in Peru, Ms.
will need to have
vaccinations for the following five diseases: cholera, malaria, Hepatitis A, chagas, and
typhoid. She will also need to continue to have preventative vaccinations for influenza.
4.
Aids for Independent Function This area includes a reacher, inspection mirror, shoe
horn, gait belt, wash mitt, cathing tray. Fifty dollars is added to the $100 amount shown
by Ms.
to cover shipping costs.
Ms. Maria
Page 7
5.
Wheelchairs and Mobility Devices A recommendation is made for a completely
foldable manual Titanium wheelchair to replace the semi-folding wheelchair prescribed in
the United States. Despite the semi-folding nature of the current chair, Ms.
cannot independently enter and exit an auto. If she is to learn to travel and work
independently (her long-term goal), then a wheelchair must be purchased which is not
over 12.5 pounds in weight, can be folded flat by her independently, and can be drawn
into an auto by her independently. Without this, she will be forced to continue to rely on
her father or mother to observe her transfer into the car seat, and, fold the chair for her in
order to stow it in the back of the car. Her current chair will be used on the second floor
of her home when it is made accessible and can also serve as a backup chair. No
replacement cost is shown for this year. Wisely, Ms.
is adamant that she does
not want a power chair until absolutely necessary in order to make sure her weight does
not escalate. As well, she can easily be outfitted in an auto with standard transmission
and hand controls using a folding chair she can fold independently.
With purchase of a manual wheelchair which folds completely and lies flat, any need for
immediate purchase of a cumbersome adapted van can be deferred until she is older (her
preference). Other items recommended within this area include immediate replacement
of her manual with a new model folding Titanium chair (every 4 years given the terrain).
With this titanium ultra light folding wheelchair, she will be able to use a standard car
without assistance for transportation in the community. Typically, an individual, when
using an ultra light folding wheelchair either transfers into the car on the drivers side and
then pulls the folded wheelchair into the vehicle behind the front seat or they transfer into
the passenger side of the car (with a bench seat) and then pull the folded wheelchair into
the front passenger area while sliding into the drivers side of the car. Neither of these
methods will work with all cars on the market. Ms.
would have to try various
methods of access with the assistance of the occupational and physical therapists
described above to determine the optimum method for access and independence.
Purchase of a power chair is recommended at age 55 from Bolivia (if Invacare has not
opened an outlet in Peru by that time) when she develops shoulder-overuse syndrome
(potentially at age 55 given the hilly terrain where she lives), to be replaced every 4
years. Other items include: maintenance of her manual wheelchair (15% of chair cost per
year lifetime to cover repair and import costs) to age 55; maintenance of a power chair
(20% of cost per year lifetime due to probable need to import parts); two clear
polycarbonate lap trays to hold items (computers, papers, etc) then replaced with just one
every 4 years with replacement of her wheelchair; wheelchair cushions (4 years), and
wheelchair gloves (4 years). Based on my direct experience with the use and repair of
both manual and electric wheelchairs, the frequency shown for replacement of the power
chair is too low (the 21 years of anticipated potential use of a power wheelchair shown in
the original plan is not realistic ). Anticipated replacement of a manual chair is five (5)
years, not an unreasonable schedule. However, given the rough terrain and her desire
for an active life style, four (4) years is recommended).
All items which require purchase out of country for Ms.
include a country tax
(IGV) of 19%. Customs costs will be estimated for the purpose of this report until
additional information is collected; shipping costs will also be estimated to include the
Ms. Maria
Page 8
costs of a skilled freight forwarder from the United States who liaisons with an identified
local Customs Agent in Peru (Cost example: a 100 pound item shipped from Houston to
Lima costs $1220.00 minimum just for shipping alone). Shipping into Peru is notoriously
problematic and cumbersome, unless a knowledgeable freight forwarder is used who
specifically has a contact person in Customs. This is based on all reports of items being
held or stolen after being in Customs for weeks or months due to some minor
issue–words spelled incorrectly, items not clearly identified, or incorrect model numbers).
C
C
C
C
C
C
C
C
C
Manual Wheelchair (replaced every 4 years)
Power wheelchair at age 55 (replaced every 4 years)
Lap tray (every 4 years)
Gloves (2 pair per year)
Wheel chair seats (every 2 years)
Locally fabricated portable ramps ($250 USD) (replaced every 10 years)
Backpack for books or other items (5 years)
Maintenance of manual wheelchair (15% annually to age 55)
Maintenance of the power wheelchair (20% annually 56 to 81 years)
Parts of the total costs for wheelchairs, maintenance and supplies are shown as annually
recurring costs. Other mobility costs are shown as one-time only as they are not
annually purchased items in which costs remain static lifetime (e.g. manual wheelchairs
and maintenance is a time-limited purchase occurring for 34 years. Powered mobility and
maintenance is a time-limited purchase which will be made for 25 years).
6.
Durable Medical Goods Items within this area include replacement of the padded tub
transfer bench, raised toilet seat with legs; sliding board and a trapeze sling for assistance
in transferring out of bed in the morning. An Easy Stand standing frame with the following
features is also included to replace the current standing frame: This Easy Stand standing
frame is configured with the following accessories for Ms.
safety and
convenience. It has a seat to reduce the chance of pressure sores, foot straps for
additional security, a mobility option that will permit Ms.
to maneuver on the
second floor of her home and perform tasks while in a standing position (this will be
particularly useful when preparing meals in the kitchen) and a no-table option to permit
closer access to cabinets and counter tops. Items added later in life include a Hoyer lift at
age 55.
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C
Tub Bench (every 2 years)
Sliding Board (every 5 years)
Raised Toilet Seat (every 5 years)
Easy Stand Standing Frame (every 5 years)
Local Fabrication of a trapeze bar (every 4 years)
Sliding Board (every 4 years)
Maintenance of Standing Frame (15% per year)
Hoyer lift (every 10 years starting at age 56)
Sling for Hoyer lift (every 4 years at age 56)
Ms. Maria
Page 9
7.
Medications The following medications are recommended for continuation:
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8.
Supplies The following supplies are used per month as noted by Dr. J. Yeliza
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C
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9.
Ditropan
Effexor
Bisacodyl
Zocor (Prescription logs show that Ms.
has been prescribed
Zocor by Dr. Munoz, her Peruvian physician. No receipts are available
indicating that she has bought this medication, which is expensive, and
possibly not within the funds available to her currently).
Redoxen
2 packages of diapers
2 boxes of gloves
120 catheters
2 packages of under pads
2 packages of ultra pads plus
1 package of wipes
1 tube of lubricant
Adapted Transportation A small two door auto is recommended to replace the
family car which is now 19 years old. An adapted van is recommended at age
55 when Ms.
switches to a power wheelchair. Hand controls will need to be
imported from either Bolivia or Colombia or the United States. Types of hand controls may
change with addition of the adapted van. The recommended auto is a two-door Toyota
Yaris Hatchback or similar model. It is strongly recommended that Sra.
test a
number of similar vehicles to be sure that she identifies one that allows her to transfer and
pull her wheelchair in behind her drivers seat. This is an access strategy used and
preferred by countless individuals with a similar injury level to Sra.
and allows
someone with a low spinal cord injury to drive a typical car avoiding the expense and
problems usually associated with a larger lift-equipped van. A new type of wheelchair has
been included in these recommendations that folds flat but is also very light-weight
allowing independent access to a car for Sra.
The cost for this car includes the
purchase and installation of hand controls.
Ms.
does not know how to drive, but her father will teach her once a safer newer
car is purchased, and, hand controls are installed. She is very nervous abut this, but has
been assured that adapting to hand controls will first be learned by her father, who will
then be able to teach her. This will increase her ability to travel independently with the
addition of the Titanium folding wheelchair and serve her well after her parents’ deaths.
Beginning at age 56 a regular lift-equipped van is recommended for Ms.
use.
Her wheelchair will be changed to a power wheelchair. This van would be modified to
permit Sra.
to drive while remaining in her power wheelchair and to enter the
van via a power lift. A power lock down would be used to secure the wheelchair into the
driving position. The van that is recommended for this purpose is a Toyota Hiace. The
Ms. Maria
Page 10
cost for the van includes all necessary modifications, taxes and other fees.
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Auto until age 55: $19,000.00 per unit – changed every 5 years for a total
of 34 years or $3,800.00 per year
Adapted van at age 56: $48,000.00 per unit – changed every 5 years for a
total of26 years or $9,600.00 per year
Maintenance on the access components of the van is estimated at
$900.00 per year.
Auto Insurance $560.00 per year
License and Taxes$500.00 per year
Cell Telephone $600.00 per year
The total life time costs for Transportation will be:
Now to age 55 (34 years): $129.00.00
Age 56 to Lifetime (age 81 – 26 years):$273,000.00
10.
Architectural Modifications The funds currently spent to create a one-bedroom suite for
Ms.
have been very well spent. To make her house completely accessible in all
aspects, a recommendation is made to add a means of access for Ms.
to the
second floor family room and bedrooms. A recommendation is made to add two chair
seats to the current staircase. The first chair seat will go to the landing half way to the
second floor. Ms.
will laterally transfer to a varnished wall-mounted bench (for
easier transfer) and scoot onto the second chair which will take her to the second floor,
where her current manual wheelchair will be kept.
C
Estimated costs until a bid can be obtained from the architect who
completed the original addition: $8,200.00 to be changed every 10 years
for lifetime or a total of $820.00 per year. Annual maintenance is
estimated at $800.00 per year. Or a total of $1,620.00 per year.
Costs and materials to hire a carpenter to modify the height of her bed to make it taller will
be minimal, approximately $80 USD charged one time only.
11.
Home/Attendant Care and Other Miscellaneous Services Currently, services in this
area are primarily provided by Ms.
52 year old mother. Her 62 year old father
is only home on the weekends at his work takes him to another town where he stays
during the week. Her father has a pre-existing back problem and her mother is developing
back problems due to pushing her daughter’s wheelchair up and down hills in the
afternoons when they are in the community. Mrs.
provides direct assistance
when Ms.
transfers from her bed to her chair (a height discrepancy makes this
necessary as the bed is higher than her chair and she has fallen); and, completing most l
household tasks--shopping, meals, meal preparation, meal clean-up, home cleaning,
window cleaning, bed changes, equipment cleaning, laundry and folding. With the
addition of a standing frame, Ms.
will be able to participate more fully in these
Ms. Maria
Page 11
household tasks. The family room and bedrooms of the house are on the second floor, to
which Ms.
has no access.
The United States based life care plan allowed two (2) hours per week for home
maintenance and household tasks. An analysis of tasks which could be performed by Ms.
was performed using the Determination of Need Protocol. It shows that she
requires 7.0 hours per week of household assistance, were she to be able to access her
second floor and participate in mealtimes, cleaning, etc.
Additionally, Ms.
commendably is out in her local community at least 5
afternoons per week for various reasons. During these periods, the elder Mrs.
assists her daughter in exiting and entering their auto, and, provides her daughter with
assistance when she cannot independently push up a hill, enter a store that is not ramped,
manage a curb crossing, or open a heavy shop door independently. These activities were
estimated to by Ms.
to require 3 to 5 hours per week of direct assistance. Four
hours per day six days per week are recommended.
A recommendation is made to hire a person to provide not only direct assistance in the
household, performing tasks Ms.
cannot independently perform, but also
assisting her in community independence. Having her mother and father continue to
perform these tasks is completely untenable given their ages and the well-documented
effects of care giver burden on mortality and morbidity. This person could also assist Ms.
when she returns to University to complete her industrial engineering degree as
the campus is inaccessible.
12.
C
Attendant/Housekeeping Services: 8.0 hours for home maintenance
per week and 4 hours per day 6 days per week for community
integration = 32 hours per week to age 55
C
Additional attendant/housekeeping supports per week after age 55 to
include: additional attendant care for two hours for help in morning and two
in the evening (14 hours), four (4) additional hours of household support
per week added to the original eight (8) shown before age 55 (12),
attendant care for assistance in the community twenty-four (24) hours per
week = 50 hours per week after age 56.
Potential Complications Costs are included for hospitalizations every three (3) years.
Hospitalization costs per day in Peru are estimated to average approximately $600 per
day. When precise costs are determined, these will be added to the final report. Given
Ms.
life expectancy, twenty-seven (27) instances of hospitalizations are
anticipated at fourteen (14) days per instances (378 days).
C
Hospitalization every three (3) years at fourteen (14) days
per instance: $226,800.00 lifetime.
Ms. Maria
Page 12
MARIA
PRELIMINARY SUMMARY COST TOTALS
FOR RESOURCES AND SERVICES
AGE 21 TO 81 YEARS
Ms. Maria
Page 13
MS. MARIA
PRELIMINARY COST ESTIMATES
FOR RESOURCES AND SERVICES
PREPARED FOR MEDIATION ON JULY 24, 2008
RESOURCE
OR
SERVICE
ANNUALLY
RECURRING
COSTS
ONETIME ONLY OR TIME
LIMITED COSTS
AGES 21 - 55
AGE 56 - 81
1.
Ph ysician Care
$196.46 Per Year
$0.00
2.
Therapeutic Services
$192.98 Per Year
$5,094.74 Lifetim e
3.
D iagnostic W ork U ps and Vaccinations
$1,385.67 Per Year
$973.68 Lifetim e
4.
Aids for Independent Function
$150.00 Per Year
$0.00
5.
W h eelchairs and M aintenance
$315.48 Per Year
Age 21 to 55: $48,565.70 Lifetim e
Age 56 to 81: $137,592.00 Lifetim e
6.
D urable M edical Equipm ent
$2,083.54 Per Year
Age 21 to 55: $0.00
Age 56 to 81: $6,007.82 Lifetim e
7.
M edications
$3,267.12 Per Year
$0.00
8.
Su pplies
$1,937.96 Per Year
$0.00
9.
Adapted Transportation
$1,660.00 Per Year
Age 21 to 55: $129,000.00 Lifetim e
Age 56 to 81: $273,000.00 Lifetim e
10.
Architectural M odifications
$1,620.00 Per Year
$80.00 Lifetim e
11.
H om e / Attendant C are
$0.00
Age 21 to 55: $257,986.56 Lifetim e
Age 56 to 81: $308,256.00 Lifetim e
12.
P otential C om plications
$0.00
$226,800 Lifetim e
$12,809.21
Age 21 to 55: $668,500.68 Lifetim e
Age 56 to 81: $957,804.24 Lifetim e
Total Average Costs Per Year (C olum n 2)
O ne Tim e O nly C osts (C olum n 3)
Ms. Maria
Page 14
#2
WHO | Life tables for WHO Member States
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Life tables for WHO Member States
Beginning with the year 1999, WHO began producing annual life tables for all Member
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10/24/2010 1:27 PM
Gmail - Chambermaid Wages Mexico
1 of 1
https://mail.google.com/mail/?ui=2&ik=e1942260c3&view=pt&search=i...
Caragonne and Associates <[email protected]>
Chambermaid Wages Mexico
Keith Sofka <[email protected]>
To: Keith Sofka <[email protected]>
Mon, Aug 30, 2010 at 12:18 PM
#15
Industry: RESTAURANTS AND HOTELS - Wage per Month
[ Notes ] [ Industries ]
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2242.341
2790.202
31072
32183
37064
35684
39274
44274
50044
50454
3555.251
2091.852
23792
27113
29014
30454
32594
36094
38524
39804
1931.591
2450.802
27012
30033
32174
34704
38264
41684
42624
44634
1580.411
1809.962
23302
22873
25444
27654
28794
31324
35164
35664
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
501
542
512
513
504
514
514
524
524
524
531
532
532
503
514
524
514
524
524
524
541
512
522
513
514
514
534
534
534
534
491
492
502
493
504
504
504
494
504
51
97 Hotel receptionist
Total men and women - Per month.
98 Cook
99 Waiter
100 Room attendant or chambermaid
Industry: RESTAURANTS AND HOTELS - Hours per Week
97 Hotel receptionist
Total men and women - Per week.
Actually worked.
98 Cook
Actually worked.
99 Waiter
Actually worked.
100 Room attendant or chambermaid
Actually worked.
To calculate the hourly wage in 2008 Pesos
3566 Hours per month x 12 months = $42,792 Pesos per year
51 hours per week x 52 weeks per year = 2,652 hours per year
$42,792 Pesos per year divided by 2,652 hours per year = 16.14 Pesos per hour.
From the ILO Database for Mexico, http://laborsta.ilo.org
8/30/2010 12:18 PM
Gmail - Average Pay Professional Nurse
1 of 1
http://mail.google.com/mail/?ui=2&ik=e1942260c3&view=pt&...
Caragonne and Associates <[email protected]>
Average Pay Professional Nurse
1 message
Caragonne and Associates, LLC <[email protected]>
Reply-To: [email protected]
To: Keith Sofka <[email protected]>
Thu, Dec 17, 2009 at 3:57 PM
Industry: MEDICAL AND DENTAL SERVICES
152 General physician
Total men and women - Per
month.
153 Dentist (general)
month.
154 Professional nurse (general)
month.
158 Ambulance driver
month.
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
10560.41 1
8570.642
88512
99043
105494
116134
124784
135444
134854
136034
4071.67 1
4299.542
64792
84023
85464
88334
79204
89264
93614
98814
3452.45 1
4036.952
45252
49183
53784
57554
63244
64404
71294
73934
2331.39 1
3269.302
33812
40903
44264
45944
51144
57164
53324
58434
Industry: REPAIR OF MOTOR VEHICLES
159 Automobile mechanic
month.
#15
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2279.46 1
2603.942
30772
36823
39074
41344
44284
46224
50784
52584
NOTES: 1Second quarter. 2Revised data; second quarter. 3Annual averages; data revised. 4Annual averages. 5Hand packer.
Industry: MEDICAL AND DENTAL SERVICES
152 General physician
week. Hours actually worked.
153 Dentist (general)
154 Professional nurse (general)
158 Ambulance driver
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
431
452
432
433
434
454
454
434
444
454
491
412
422
413
414
434
424
444
424
434
431
432
422
423
424
424
424
424
424
424
491
442
412
433
454
494
454
454
434
444
Industry: REPAIR OF MOTOR VEHICLES
159 Automobile mechanic
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
501
502
492
493
494
504
524
524
514
514
NOTES: 1Second quarter. 2Revised data; second quarter. 3Annual averages; data revised. 4Annual averages. 5Hand packer.
Average earnings/month = 7393 x 12 mo = 88,716 pesos per year
Average hours/week = 42 x 52 = 2184 hours per year
Average pay per hour = 88,716 pesos per hour/2184 hours per year = 40.62 pesos per hour
12/17/2009 3:57 PM
Statistics and databases - What we do
1 of 1
http://www.ilo.org/global/What_we_do/Statistics/lang--en/index.htm
#15
> ILO Home > What we do
Statistics and databases
Statistics
QUICK LINKS
Labour statistics play an essential role in the efforts of member States to achieve decent work for
all and for the ILO's support of these efforts. These statistics are needed for the development and
evaluation of policies towards this goal and for assessing progress towards decent work. They are
also an important tool for information and analysis, helping to increase understanding of common
problems, explain actions and mobilize interest.
LABORSTA - database of labour statistics
Covers official core labour statistics and estimates for over 200 countries since
International Conference of
Labour Statisticians
International Standard
Classification of Occupations
Statistical guidelines and
standards
List of ILO databases
1969. Also provides methodological descriptions of main national statistical
sources.
SEE ALSO
Key Indicators of the Labour Market (KILM)
Department of Statistics
KILM is a comprehensive database of country-level data on 20 key indicators of the labour
Policy Integration Department
market, a training tool on development and use of labour market statistics, highlights of current
How to find labour statistics
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Compiles web sites which contain data from national statistical agencies, the ILO and other
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ILO Library.
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(IPEC-SIMPOC)
SIMPOC provides access to a comprehensive compendium of child labour
statistics and methodological guidance material. Processed child labour data
can be accessed in the form of national child labour survey reports, statistical
country-briefs and other resources derived from household-based SIMPOC surveys. A large
number of micro-datasets are also available.
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CISDOC - Occupational Safety and Health database
Nearly 50,000 citations of documents on occupational health and safety: law
and regulations, chemical safety data sheets, training material, journal articles,
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Freedom of Association, discussions of the Conference Committee,
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LABORDOC
Labordoc, the ILO Library's database, contains references and full text access to
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NATLEX - database of national labour, social security and related human
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Records in NATLEX provide abstracts of legislation and relevant citation
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Each record in NATLEX appears in only one of the three ILO official languages
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Database of Conditions of work and Employment Laws: Working Time - Minimum
Wages - Maternity Protection
Copyright and permissions 1996-2010 International Labour Organization (ILO) - Disclaimer
8/31/2010 8:57 PM
#15
Go to http://
laborsta.ilo.org
/default.html
on the left side
click statistics
by country
on the next screen,
scroll down and
choose Mexico and
click Go!
Scroll about one-half of the way down and
find O1 Occupational wages and hours of
work.
You can select view or download the entire
file. I find it easier to select view.
Scroll down a bit and click on Medical and dental services.
This will jump the database directly to the section that
includes nursing.
Here is the section on nursing wages. Now scroll down a bit and you will
see the section Average hours of work.
Again select Medical and dental services and you will be taken
to the average hours worked for medical and dental services.
Here is the section on hours worked by professional nurses
Banco de México
1 of 1
http://www.banxico.org.mx/
#16
El Banco de México es el banco central del Estado Mexicano, constitucionalmente autónomo en sus funciones y administración, cuya finalidad es proveer a la economía del país
de moneda nacional. En el desempeño de esta encomienda tiene como objetivo prioritario procurar la estabilidad del poder adquisitivo de dicha moneda. Adicionalmente, le
corresponde promover el sano desarrollo del sistema financiero y propiciar el buen funcionamiento de los sistemas de pago.
Principales indicadores
Inflación anual (Sep. 2009-Sep. 2010, %)
Objetivo de inflación
Intervalo de variabilidad porcentual
Inflación
Inflación subyacente
Inflación mensual (Sep. 2010, %)
Inflación
Inflación subyacente
Mercado cambiario
FIX determinado el 22/10/2010 (Pesos por dólar)
FIX prom. mov. últimos 20 días aplica 25/10/2010
Noticias y novedades
Principales gráficas
Mercado de valores (%)
Tasa de interés objetivo (24/10/2010)
TIIE 28 (22/10/2010)
TIIE 91 (22/10/2010)
CETES 28 (19/10/2010)
UDIs (04/04/1995 = 1.0)
UDIS (24/10/2010)
0.52
0.38 Reservas internacionales
Reservas internacionales (millones de dólares) (15/10/2010)
12.3877
12.4679
4.50
4.8550
4.9400
4.03
3.00
±1 punto
3.70
3.62
4.459870
109,697.2
Discursos y presentaciones de la Junta de Gobierno
Buscar
Navegación por audiencias
Información para la
prensa
Publicaciones recientes
¡Visítanos!
Empleo o servicio social
Museo interactivo
(MIDE)
Archivo fotográfico
Portales especializados
Mercado cambiario
(Tipos de cambio)
Mercado de valores
(Tasas de interés)
Inflación
Premio Cont@cto
Banxico
Calendarios de publicación
Calendario de decisiones de política monetaria 2010
Calendario de difusión 2010
Mis favoritos Banxico
10/24/2010 1:38 PM
Calculadora de inflación
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http://www.banxico.org.mx/SieInternet/consultarDirectorioInternetAction.do?accion=consultarC...
#16
Calculadora de inflación
Ayuda
La calculadora de inflación le permite conocer cuál ha sido la inflación en el período que usted defina. Lo único que debe hacer es indicar el período y oprimir el botón de calcular.
Cálculo de inflación
IPC Por objeto del gasto Nacional
5.1 Salud 5.1.2 Servicios médicos
58 Servicios médicos Cuidado dental
Período: Ene 1980 - Sep 2010
Base=2Q Jun 2002
Inflación en un período determinado
Seleccione el período de interés y oprima el botón de calcular.
DE
/
A
/
Inflación de Dic 2009 a Sep 2010: 2.66%
Tasa Promedio Mensual de Inflación de Dic 2009 a Sep 2010: 0.29%
10/24/2010 1:53 PM
Consulta de Series - Banxico
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#16
Banco de México
Índices de Precios al Consumidor y UDIS
INPC
Fecha de consulta: 24/10/2010 01:48:09
Título
IPC Por objeto del
gasto Nacional, 5
Salud y cuidado
personal
IPC Por objeto del
gasto Nacional, 5.1
Salud
IPC Por objeto del
gasto Nacional, 5.1
Salud 5.1.1
Medicamentos y
aparatos
IPC Por objeto del
gasto Nacional, 5.1
Salud 5.1.1
Medicamentos y
aparatos, 56
Medicamentos
IPC Por objeto del
gasto Nacional, 5.1
Salud 5.1.1
Medicamentos y
aparatos, 56
Medicamentos
Antibióticos
IPC Por objeto del
gasto Nacional, 5.1
Salud 5.1.1
Medicamentos y
aparatos, 56
Medicamentos
Analgésicos
IPC Por objeto del
gasto Nacional, 5.1
Salud 5.1.1
Medicamentos y
aparatos, 56
Medicamentos
Cardiovasculares
IPC Por objeto del
gasto Nacional, 5.1
Salud 5.1.1
Medicamentos y
aparatos, 56
Medicamentos
Nutricionales
IPC Por objeto del
gasto Nacional, 5.1
Salud 5.1.1
Medicamentos y
aparatos, 56
Medicamentos
Anticonceptivos y
hormonales
IPC Por objeto del
gasto Nacional, 5.1
Salud 5.1.1
Medicamentos y
aparatos, 56
Medicamentos
Gastrointestinales
IPC Por objeto del
gasto Nacional, 5.1
Salud 5.1.1
Medicamentos y
aparatos, 56
Medicamentos
Expectorantes y
descongestivos
IPC Por objeto del
gasto Nacional, 5.1
Salud 5.1.1
Medicamentos y
aparatos, 56
Medicamentos Otros
medicamentos
IPC Por objeto del
gasto Nacional, 5.1
Salud 5.1.1
Medicamentos y
aparatos, 56
Medicamentos
Dermatológicos
IPC Por objeto del
gasto Nacional, 5.1
Salud 5.1.1
Medicamentos y
aparatos, 56
Medicamentos
Antigripales
IPC Por objeto del
gasto Nacional, 5.1
Salud 5.1.1
Medicamentos y
aparatos, 56
Medicamentos
Material de curación
IPC Por objeto del
gasto Nacional, 5.1
Salud 5.1.1
Medicamentos y
aparatos, 57
Aparatos médicos
IPC Por objeto del
gasto Nacional, 5.1
Salud 5.1.1
Medicamentos y
aparatos, 57
Aparatos médicos
Lentes y otros
aparatos
IPC Por ob
gasto Nacio
Salud 5
Medicame
aparato
Aparatos m
Prótesis d
Periodo
Ene 1969 - Sep 2010 Ene 1980 - Sep 2010 Ene 1980 - Sep 2010 Ene 1980 - Sep 2010 Ene 1969 - Sep 2010 Ene 1980 - Sep 2010 Ene 1995 - Sep 2010 Ene 1969 - Sep 2010 Ene 1969 - Sep 2010 Ene 1980 - Sep 2010 Ene 1980 - Sep 2010 Ene 1995 - Sep 2010 Ene 2002 - Sep 2010 Ene 1980 - Sep 2010 Ene 1995 - Sep 2010 Ene 2002 - Sep 2010 Ene 1995 - Sep 2010 Ene 2002 - S
disponible
Periodicidad
Cifra
Unidad
Base
Mensual
Mensual
Mensual
Mensual
Mensual
Mensual
Mensual
Mensual
Mensual
Mensual
Mensual
Mensual
Mensual
Mensual
Mensual
Mensual
Mensual
Indices
Indices
Indices
Indices
Indices
Indices
Indices
Indices
Indices
Indices
Indices
Indices
Indices
Indices
Indices
Indices
Indices
Sin Unidad
Sin Unidad
Sin Unidad
Sin Unidad
Sin Unidad
Sin Unidad
Sin Unidad
Sin Unidad
Sin Unidad
Sin Unidad
Sin Unidad
Sin Unidad
Sin Unidad
Sin Unidad
Sin Unidad
Sin Unidad
Sin Unidad
2Q Jun 2002
2Q Jun 2002
2Q Jun 2002
2Q Jun 2002
2Q Jun 2002
2Q Jun 2002
2Q Jun 2002
2Q Jun 2002
2Q Jun 2002
2Q Jun 2002
2Q Jun 2002
2Q Jun 2002
2Q Jun 2002
2Q Jun 2002
2Q Jun 2002
2Q Jun 2002
2Q Jun 2002
Inflación acumulada
anual
anual
anual
anual
anual
anual
anual
anual
anual
anual
anual
anual
anual
anual
anual
anual
SP874
SP875
SP876
SP648
SP801
SP917
SP649
SP650
SP803
SP802
SP918
SP57061
SP800
SP925
SP65213
SP915
Mensu
Indic
Sin Uni
2Q Jun
Aviso
Tipo de Inflación acumulada
información
anual
Fecha
SP15
Inflación ac
anua
SP570
Ene 2009
1.01369111
0.50686456
0.38247590
0.41641440
0.33103658
0.18311924
0.49864037
0.03498206
0.76213373
0.06537156
0.72830497
0.70487244
0.36275069
0.56164036
1.70215300
0.18295007
0.15978832
0.2
Feb 2009
1.76454435
1.18293135
1.01132771
1.09048100
0.26261775
1.04263097
1.92874097
1.30325333
1.13839219
0.23639413
2.25444796
1.34375944
0.59890879
1.96907643
3.07000009
0.54715623
0.25944126
1.3
Mar 2009
2.39927818
1.83302412
2.23483183
2.46081399
1.22531912
2.44339183
3.33091770
2.70870916
2.56408715
2.44450020
4.02073089
2.50621311
1.51096766
3.15839325
5.43651165
0.89950451
0.35823511
2.3
2.5
Abr 2009
3.19485309
2.37476809
3.16798928
3.42145980
2.39880578
3.69684643
3.81825556
4.12856937
3.84853494
2.73371984
4.91820906
3.05568061
1.71455222
4.83130778
6.18593533
1.67280735
1.35562352
May 2009
3.71111373
2.65602968
3.78427801
4.10359906
4.10443893
3.20830321
4.07488914
4.68348092
3.84072126
3.98964620
6.14471477
3.65756643
1.44952213
5.94258194
6.66910520
1.90149494
1.61076939
Jun 2009
3.99435095
3.01298701
4.52131186
4.86310124
5.14661672
4.73069308
5.26231808
4.49553807
4.20135237
4.98606727
5.84005964
3.92705834
3.16777589
6.53690684
7.43979516
2.50285859
2.40541562
2.7
Jul 2009
4.38664627
3.29721707
5.06361803
5.44029600
6.70435462
5.42668135
5.64460903
4.75070136
3.94830954
5.09766115
6.85008100
4.01401111
3.41207738
7.44473646
6.50067627
2.84250201
2.65970242
3.3
2.6
Ago 2009
4.70048252
3.77439703
5.85090419
6.29263370
7.85365281
6.08482948
7.10994688
5.45034262
5.16664162
5.39282366
7.26656249
4.67509882
3.80814190
7.67486226
7.62438647
3.24566976
2.86158551
4.2
Sep 2009
4.79777176
3.87161410
6.09448830
6.55634040
7.60209265
7.87412748
7.07205021
5.42084794
5.52667168
5.60148440
7.74110765
4.88045536
4.39890731
7.59148334
6.76012488
3.36933045
3.02309199
4.2
Oct 2009
4.84641638
4.13580705
6.35621907
6.83551968
8.05061612
7.75249846
7.20568583
5.97644541
6.21187077
5.83787853
7.40491176
4.89340577
5.03853301
8.37924732
5.97072059
3.52771778
3.17428954
4.4
Nov 2009
4.87701542
4.31688312
6.47766215
6.97208207
8.46734901
7.41328865
7.31206244
6.27207814
6.76483847
5.82665311
6.86011670
5.13823023
4.89935519
8.25718059
6.64868957
3.56244442
3.13563108
4.6
Dic 2009
4.93585972
4.50983302
6.69472421
7.21762529
8.61869977
8.37956362
8.17038874
5.48463876
6.61697971
6.45659725
7.40061074
5.52427586
4.85345613
7.87163649
6.38839031
3.60733494
3.11930861
4.8
Ene 2010
1.18134374
0.85992033
0.48472875
0.51449689
0.62226407
0.61910818
1.32884240
0.38690379
0.74583953
0.46954472
-1.09326819
0.44297695
0.88466834
-0.33453088
0.22627871
0.30329289
0.35073104
Feb 2010
1.72341603
1.49403168
1.04861025
1.08107091
1.47040110
1.11476882
0.92318283
0.68017037
1.25715961
1.12517057
-0.03403949
0.65219297
2.47537685
0.87250107
1.05543429
0.85265361
0.81309618
0.9
Mar 2010
2.15782154
1.88671207
1.20168249
1.21345974
1.43477044
0.26185845
1.56486251
1.11389277
2.29389347
0.61468800
0.70815479
0.72816527
2.66388958
0.02040577
2.03490929
1.12978647
1.06135710
1.3
Abr 2010
2.61166689
2.24388789
1.40185387
1.38725930
1.50794055
0.88159010
1.33990584
1.32457652
3.16601272
0.29152711
1.39094683
1.09926073
1.60200515
-0.18736203
2.08768100
1.49684445
1.52622152
1.4
May 2010
2.99522976
2.65929119
1.84537087
1.82960114
1.70963555
1.52376677
1.78490209
1.50274734
3.58656925
0.51110284
1.67327433
1.66496216
3.21177675
0.25476289
4.20014872
1.94320003
1.98025576
0.1
1.8
Jun 2010
3.03485712
3.00936610
2.39224434
2.41374334
2.34526112
2.57307098
2.94840748
1.86949312
4.26588644
0.06326758
2.00966454
2.38202379
3.44830021
0.79396979
4.59753572
2.26529544
2.40596493
1.9
Jul 2010
3.18215124
3.32890710
2.78669972
2.85043826
3.26720452
4.02825577
2.70624101
1.80121598
4.52915708
0.61965017
1.77806255
2.55617567
3.35580895
1.03265541
5.88084787
2.39691312
2.58507935
1.9
Ago 2010
3.53655436
3.66975083
3.15498891
3.24823220
3.48862364
4.56007781
3.15369580
2.33572845
4.84767510
0.78650292
2.86932842
3.31180785
3.27179016
1.00111923
5.89683929
2.58657336
2.76419378
2.1
Sep 2010
3.89992972
3.96301846
3.53112796
3.66986868
4.24386644
4.13299915
3.89679037
2.42026205
5.39394759
1.17913410
3.31584638
4.05925839
4.01383839
0.85147694
5.56981458
2.68303849
2.88082643
2.1
10/24/2010 1:49 PM
Estadísticas
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http://www.banxico.org.mx/estadisticas/index.html
#16
Agregar a mis favoritos Banxico
El Banco de México asigna la mayor importancia a la difusión de información confiable y
calidad, a fin de facilitar la toma de decisiones y permitir al público evaluar la ejecución
las políticas de la Institución. En esta sección se puede consultar un amplio conjunto
estadísticas económicas y financieras de la base de datos que utiliza el Banco de México
su análisis y en la formulación de sus políticas.
Estadísticas
de
de
de
en
Disposiciones
Información general
Servicios
Publicaciones y discursos
Material educativo
¿Cómo consulto y descargo
información estadística? (FLASH)
Suscripciones
Otras fuentes oficiales de información
estadística
RSS
Webservices
| Twitter
Buscar
prensa
¡Visítanos!
Museo interactivo
(MIDE)
Mercado cambiario
(Tipos de cambio)
Mercado de valores
(Tasas de interés)
Inflación
Divulgación de información al FMI
Billetes y monedas
Billetes y monedas en circulación
Billetes y monedas en
circulación
Número de billetes y monedas en
circulación
Circulación de billete
Circulación de moneda
Depósito de billete deteriorado
Duración promedio del billete
Falsificación de billete
Sistema financiero
Mercados financieros (Tipo de cambio,
tasas de interés y derivados)
Intermediación financiera
Banca múltiple: saldos, plazos,
costos y mercados
Banca de desarrollo: saldos,
plazos, costos y mercados
Tasas de captación del público,
en ventanilla
Financiamiento e información
financiera de intermediarios
financieros
Política monetaria e inflación
Política monetaria
Gráficas de coyuntura (FLASH)
Tasa objetivo de fondeo
bancario
Instrumentación de la política
monetaria
Información sobre Banco de
México
Agregados monetarios y flujo
de fondos
Financiamiento e información
financiera de intermediarios
financieros
Inflación
Indices de Precios al
Consumidor y UDIS
Indices de Precios al Productor
y Comercio Exterior
Otros indicadores
Tasas de interés y precios de
referencia en el mercado de
valores
Balanza de pagos
Finanzas públicas
Producción
Laborales
Sistemas de pago
Sistemas de pago de alto valor
Sistemas de pago de bajo valor
Provisión de liquidez en los sistemas
de pago
Agregados monetarios y flujo
de fondos
Capitalización de los bancos múltiples
6/16/2010 7:30 PM
Indices de precios
#16
Billetes y monedas
Política monetaria e inflación
Sistema financiero
Sistemas de pago
Agregar a mis favoritos Banxico
Estadísticas
Disposiciones
Servicios
Publicaciones y discursos
Material educativo
Suscripciones
RSS | Twitter Buscar
Applus México, S. A. de C. V.
certifica que la elaboración del
Índice Nacional de Precios al
Consumidor y la elaboración del
Índice Nacional de Precios Productor
es conforme con los requisitos de la
Norma NMX-CC-9001-IMNC-2000 / ISO
9001:2000
Seleccionar
nivelnivel
Seleccionar
Índices de Precios al Consumidor y UDIS
Cuadros Resumen
Variaciones en por ciento del Indice Nacional de Precios al Consumidor
Indice Nacional de Precios al Consumidor y sus componentes mensual quincenal
prensa
Indice Nacional de Precios al Consumidor, clasificación objeto del gasto mensual quincenal
Indice Nacional de Precios al Consumidor, ciudades que lo componen por orden alfabético mensual quincenal
¡Visítanos!
Indice Nacional de Precios al Consumidor, ciudades que lo componen por mayor variación mensual quincenal
Museo interactivo (MIDE)
Mercado cambiario (Tipos
de cambio)
Mercado de valores
(Tasas de interés)
Inflación
Variaciones en por ciento de los diez productos con mayor variación
Estructuras de Información
Valores de UDIS
Resumen de Indices de precios consumidor y productor
Principales índices mensuales quincenales
Inflación
Indice de precios al consumidor
Por objeto del gasto y actividad económica
Por estrato de ingreso y objeto del gasto
Inicio | Contacto | Ley de transparencia | Mapa del sitio | Salvedad al uso de esta página http://www.banxico.org.mx/politica-monetaria-e-inflacion/estadisticas/inflacion/indices-precios.html[6/16/2010 7:35:03 PM]
Ligas

international life care planning

Transcription

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