June 27, 2003

Expert TBI Attorney, Esq.

Law Offices of Expert TBI Attorney
Honolulu, HI 96813

Regarding: James K. O
Date of Injury: 11/14/99

Dear Mr. TBI Attorney;

Life Care Plan

James K. O
Date of Birth: 11/23/93
Date of Injury: 11/14/99
Date of Report: 06/26/03

This report has been prepared in response to request from you for James K. O, regarding Life Care Plan due to a
severe traumatic brain injury from a motor vehicle roll-over incident on 11/14/99 in which he was ejected from the
vehicle.

This Life Care Plan is a report specific to your request and represents a comprehensive listing of needed services,
frequency of services and interventions, as well as associated costs, as result of Mr. O disabling condition. This report
consists of brief narrative, a listing of diagnoses, procedures completed to date, and central observations for report
development and life expectancy as they relate to Mr. O life long care needs.

I have carefully considered the records provided by your office; listed within this report; I have personally
communicated with Pediatric Physiatrist, MD, consulted medical providers, medical supply vendors, product catalogs,
vendor websites, billing services, and Fee Analyzers to obtain costs for services and products referred to in this
projection.

This projection is based on central observations derived from data collected from the records provided and
recommendations of Mr. O treatment providers as they appear within the records. I have evaluated the nature of Mr. O
injuries, his current status relative to the prognosis offered by his treating doctors, and partial review of medical
literature relative to Mr. O injuries. With careful consideration the Life Care Plan takes into account Mr. O needs,
potential for successful outcome, and quality of life. The life care plan is based on the central observation that Mr. O
injuries have a lifelong impact that will profoundly affect the nature and quality of his life. The goal of this projection
then is to support a quality of life that preserves dignity, offers opportunities for increased function, pleasure and
happiness, satisfaction of achievement, and minimizes complications and untoward events, as well as maximizes Mr.
O safety and safety of the general public.

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Contents
Introduction 2
Medical History 3
Diagnosis 3
Secondary Diagnoses 3
Procedures Performed 4
Review of Testing and Evaluations 5
Summary of Deficits Identified as Arising from James’s Brain Injuries 9
Current Status 9
Life Expectancy 11
Central Observations of Life Care Plan Development 11
Needs 14
Evaluations 14
Medical Care 17
Diagnostic Testing 18
Therapeutic Modalities 19
Psychosocial Support 20
Future Procedures 21
Potential Complications 21
Equipment/Supplies 23
Orthotics 25
Medications 25
Educational/Vocational 25
Housing/Home Furnishings 26
Attendant/Respite/Residential Care 27
Transportation 28
Additional Services 28
Documents Reviewed 29
Sources 0

Introduction
?James K. O is a 9 year old male referred by Expert TBI Attorney for life care planning. James sustained a severe
brain injury with right side hemiparesis as result of an automobile crash on November 14, 1999. Prior to the evening of
November 14, James was well developed, healthy boy. James was the product of a full term, uncomplicated
pregnancy and postnatal course. James had received regular medical care and was current with immunizations. Child
hood illnesses include only chicken pox and seasonal asthma, for which he occasionally uses inhalers. He has no
known allergies to medications or food. Prior to the brain injury of 11/14/1999, James had reached the normal
developmental milestones at expected ages. James was a bright, inquisitive and active 1st grader in Kona. James lived
with his mother, brother and maternal grandmother in the grandmother’s 2 nd story condominium. James’s parents are
unmarried and separated. James’s mother, Angela K, worked to support James and his brother as a clerk at Short’s
Drug in Kailua Kona, Hawaii. His father lived on Oahu and worked as an auto mechanic.

Today, James is unable to be left alone and is unable to care for him self as would be age appropriate due to cognitive
and language and physical deficits. With right sided hemiparesis James is unable to use right upper extremity. James
has right wrist dorsiflexion, thumb extension and abduction, and no active supination. He must use resting and active
wrist orthotics (braces) and needs reminder to use right upper extremity to assist. His hemiparesis affects his ability to
walk and he must wear ankle foot orthosis for support of foot drop and to prevent further contracture of the right ankle.
He experiences undo fatigue after walking short distances and has right hip pain and soreness with walking. James
attends public elementary school with an individualized educational plan and special education. James continues to
live with his mother and brother at the home of his maternal grandmother. He is becoming obese and beginning to

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experience social isolation due to deficits stemming from his injuries. Most painful to him is his diminished ability to
actively play with his friends and cousins.

This report is to outline necessary services and devices that James O will require in the future as result of his injuries.
Continuity of medical care will ensure early detection of complications. An accessible home is recommended for safety
and increase independent function. Equipment is needed to maximize comfort, physiologic function, and
independence. Psychological support may help James facilitate a healthy and productive adjustment to his chronic
handicaps. Attendant care and supported living is required to support James’s safety, independence and socialization
and quality of life.

According to Dr. Pediatric Physiatrist, with appropriate care James has a nearly normal life expectancy of an additional
65 years. All costs contained within this plan are based on today’s dollars, without regard for inflation, cost of living
increases, applicable taxes, or other economic considerations. This report may be amended or supplemented upon
the receipt of additional medical records or evaluations. Opinions expressed within this report are held to a reasonable
degree of professional certainty.

_________________________
Wayne A. Eklund, RN, CNLCP

Medical History
On the evening of November 14, 1999, James was a passenger in a vehicle traveling in a rural area on the island of
Hawaii when the vehicle in which he was riding was involved in a roll-over motor vehicle accident. James was ejected
from the vehicle suffering multiple traumas including a severe traumatic brain injury. He was taken by ambulance and
evaluated at Ka’u Hospital, then transferred to Hilo Hospital where he was orally intubated and CT scan of the head,
neck, chest abdomen and pelvis was performed. He was ultimately transferred to Queen’s Hospital on Oahu for
definitive treatment. On 12/08/1999 James was transferred to Kapi’olani Medical Center for women and children and
then to the Rehabilitation Hospital of the Pacific on 2/01/2000 for rehabilitative therapies. He was discharged on
2/19/2000 from the rehabilitation hospital to outpatient therapies. On 3/22/00 James was readmitted to Queen’s for
cranioplasty using his own frozen fractured bone pieces.

Diagnosis
James’s diagnosis include

 Roll-over MVA w/ ejection

Head Trauma w/
o Bifrontal abrasions to the scalp and multiple facial abrasions
o 2 cm. laceration to frontal scalp
o Large closed, complex comminuted and depressed left frontoparietal temporal skull fracture (6
pieces) and linear fracture in the left middle cranial fossa
o Skull fracture fragment laceration of high left parietal brain to depth of 1.5 cm
o Frontal dural tear over left frontal lobe
o Dural tear over left parietal lobe
o Ruptured pia mater over left side of brain
o Subarachnoid hemorrhage
o Left side brain hemorrhagic contusions with massive cerebral edema and necrotic brain: frontal
and parietal lobes
o Hemorrhage in the left basal ganglia and genu of the internal capsule
o Left thalamic (brain) contusion
o Deep brain shear injuries

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 o Hemorrhage into the left basal ganglia
o Hemorrhage into the left lateral and 4th ventricles

 Complex, non-displaced fractures of cervical arch of vertebrae C1

 C4 left pedicle and left C3-4 facet and lamina fracture
 Contusions and abrasions: left maxillary and mandibular face, large area over anterior chest, left antecubital
fossa, right anteromedial thigh, right scrotum, bilateral knees, dorsum of right foot and bilateral dorsal toes.
 Bilateral pulmonary contusions

Secondary diagnoses include:

 Coma, due to severe brain injury

 Sensorineural hearing loss
 Right sided hemiplegia w/ severe deficits
 Right homonymous hemianopsia
 Ptosis, left eye
 Neurogenic pulmonary edema
 Respiratory failure
 Right upper lobe pneumonia
 Candida parpsiliosis fungemia
 Ascites (massive 3rd spacing of fluid in soft tissues of the peritoneal cavity)
 Ileus
 Right frontal hygroma

Procedures Performed in Acute Treatment

11/14/99
 Blind oral endotracheal intubation, failed
 Repair of scalp laceration
 Intravenous sedation
 Oral endotracheal intubation w/ uncuffed tube, air leak, removed
 Oral endotracheal intubation w/ cuffed tube
 Mechanical ventilation (Respirator), manual ventilation
11/15/99
 General endotracheal anesthetic
 Craniotomy, large 16 cm X 14 cm craniectomy on the left w/ repair of dural defect (bone flap left out)
 Jackson Pratt drain placed in floor of left temporal fossa
 Transfusion 4 units of packed red blood cells
 General endotracheal anesthetic
 Exploratory laparotomy
 Placement of feeding tube jejunostomy
 Insertion of triple lumen catheter in the left subclavian vein
11/16/99
 Local anesthesia to scalp
 Scalp incision X 2 (1st aborted due to excessive bleeding, suture X 1)
 Twist drill opening in the right frontal skull
 Insertion of Camino intracranial pressure monitoring catheter and bolt
11/22/99
 General endotracheal anesthetic
 Right frontal bur hole evacuation of right subdural hygroma
 Insertion of small ventricular catheter into left lateral ventricle for purposes of monitoring intracranial pressure

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11/26/99
 Lumbar puncture w/ insertion of cerebral spinal fluid drain
12/08/02
 Removal of Jejunostomy tube
 Re-insertion attempt failed
12/10/99
 Attempted replacement of 10 Fr. Jejunostomy tube, failed
 5 Fr. Jejunostomy tube inserted, extravasations into the peritoneum, removed
 Prophylactic antibiotics, Clindamycin and Gentamycin, started
12/13/99
 Hyperalimentation and intralipid feedings began
1/06/00
 Nasogastric tube inserted for Amphotericin B administration, 2º fungemia
3/22/00
 General endotracheal anesthetic
 Left frontoparietal temporal cranioplasty using own frozen bone flaps (6 fractured pieces)
 Transfusion 1 unit packed red blood cells

Review of Testing and Evaluations

April Hearsogood, clinical audiologist, evaluated James’s hearing in 2001 and found James to have mild hearing
loss which she felt may affect James in school. She recommended that James have access to assistive hearing
devices during periods of instruction and that adjustments within the classroom should be taken into consideration.

Reginald C. Gentle, Ed.D., evaluated James in June of 2001. Dr. Gentle appears to have reviewed James’s clinical
and educational records and completed a clinical observation, as well as interviewed James’s mother. Dr. Gentle
opines that James is at great risk for academic failure and neurodevelopmental problems due to learning and cognitive
problems and that these deficits will limit his ability to achieve success in school which will impact his ability to lead a
fully functional adult life. Dr. Gentle sees James’s prognosis as guarded but that receipt of ongoing intensive therapies
and a sound educational program is as pertinent to his recovery as are the severe deficits he has sustained as result of
his injuries. Dr. Gentle recommends within the school system an experienced group of therapists trained in traumatic
brain injury education and rehabilitation provide intensive one-on-one daily speech, occupational and physical therapy
for 3-5 years to help compensate for his deficits, rather than 30 minutes of therapy per week he has been receiving
within his IEP, in order that James not fall further behind his peers. Dr. Gentle recommends that James also receive
one-on-one cognitive therapy and speech therapy to compensate for deficits in language function and intensive speech
therapy for many years [NOS] to maintain the current compromised skills. James’s educational programming must
anticipate his future needs in such areas as vocational opportunities, independent living and everyday life skills such as
safely taking care of himself, participating in his community of choice. He anticipates that James will need a high level
of support services all of his life.

Aurora Austrialis, PhD., neuropsychologist, evaluated James in December 2000 and again in April 2003. Dr.
Austrialis found that James’s expressive language skills have improved since the 2000 evaluation and that James now
demonstrates a capacity for functional communication, though he continues to have slowness and lack of fluency in
verbal output. James’s right hemiparesis remained dense and he rarely used his right arm in test activities. In visually
based tasks James was observed to have developed a careful scanning approach help to compensate for spatial
neglect (right homonymous hemianopsia), as compared to 2000. James continued to show fluctuations in attentional
focus with increasing symptoms when he became fatigued. In April 2003 Dr. Austrialis administered testing geared
more toward academic and educational needs

 Weschler Intelligence Scale for Children – III (WISC-III)

 NEPSY Developmental Neurological Assessment (selected subtests)
 WRAT-3 Wide Range Achievement Test -3

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  Developmental Test of Visuo-motor Integration (BEERY)
 Peabody Picture Test -3
 Contingency Naming Test
 Spatial Learning Test

Neuropsychological testing indicates that James is functioning below average levels on tests tapping general
intelligence. His cognitive profile reveals discrepancies between linguistic and non-verbal skills, with non-verbal skills
being an area of relative strength. He is currently performing age appropriate tasks in visual planning, visual memory
and learning and non-verbal problem solving; and these skills are at their best when James is not required to provide
complex motor responses, particularly those requiring the right side extremities.

Primary deficits found in April 2003 Neuropsychological Testing were summarized:

 James’s intellectual ability has shown some improvement since 2000 evaluation. Full Scale IQ is 71, 3 rd
percentile, is now borderline and up from Full Scale IQ of 63, 1 st percentile, which represented mild mental
retardation. Verbal IQ was 64 and Performance IQ 68 in 2000; in 2003 Verbal IQ was 74, Performance IQ
73.
 Language skills are at levels expected of a 6-7 year old with improvements demonstrated between 2000 and
2003
 Visuo-motor and fine motor difficulties at the levels expected of a 5-6 year old, and these are associated with
right side hemiparesis
 Reduced attention skills
 Severe difficulties registering and learning new information from the environment where information is
spoken or he has to hear the information
 Slowed speed of process for both motor and oral tasks
 Reduced educational progress

James’s expressive output is slow with word finding difficulties and poor fluency; he is now able to respond in
sentences with appropriate content. James’s language skills have improved but are at levels of linguistic ability far
below age expectations, with rapid naming, verbal fluency and language comprehension for single words and
instructions falling into the 6-7 years of age range. Despite his functional language recovery his language difficulties
remain severe, and global. Dr. Austrialis recommends ongoing intensive speech therapy for continued recovery, as
well as specialized support to enable James to communicate adequately in both comprehending instructions and
expressing his thoughts and ideas. She states that this support will become more important as James moves through
school and linguistic demands increase.

Nonverbal skills remain inconsistent in WISC–III, NEPSY Developmental Neurological Assessment, and
Developmental Test of Visual-Motor Integration. James now utilizes a visual scanning technique by moving his gaze to
the extreme side of the visual stimulus and then systematically scanning the material. Although this represents an
improvement from previous evaluation it continues to represent slowed processing time for visually based tasks.
Visual perception and visual closure were below age expectations, although tasks of analysis and planning of visual
material his performances improved with tasks of block construction, jigsaw completion and problems solving within the
normal range despite difficulties with fine motor coordination and right-sided hemiparesis. Visual motor skills continued
to be significantly depressed for simple and complex activities and speed of response was slower than expected;
James’ scores reflected minimal improvement in these areas, with performance falling into the range of 5-6 years of
age. Given James’ neurological impairment these visuomotor and speed of processing difficulties are expected to be
ongoing. Educational assistants (teacher’s aides) are recommended to compensate for these difficulties in school.
James should be introduced to computer technology at home and in the classroom to compensate for motor difficulties
and ensure best quality representation of visual and written information. Occupational therapy will be important in this
domain. James will also require additional time when he is required to work within this domain to compensate for
slowed processing speed.

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Attentional skills demonstrated on NEPSY Neurological Domain Assessment and Contingency Naming Tests have
showed some improvement although they remain reduced. He has difficulty focusing attention with a tendency to lose
track of tasks, and trouble with shifting attention flexibility or dividing attention across tasks. These problems hinder
James’s ability to cope with noisy distracting environments. He may be distracted in typical classroom activity and will
need individual support and supervision within the classroom and rehabilitation sessions to focus his attention
appropriately.

Memory and learning skills were assessed with NEPSY Neurological Domain Assessment and Spatial Learning Test.
James demonstrated severe difficulties on tasks of verbal registration of new material and instructions. His ability to
register information from his environment and store it away for later recall is depressed as it is with auditory-verbal
information. In conjunction with impairments of language, expression and comprehension, cause James to
misinterpret information or instructions that are presented aurally (auditory-verbal). It is recommended that he be
seated close to his teacher, with minimum distractions. Verbal instructions should be presented in short sentences with
pauses for processing time. Repetition and written instructions will be helpful and he should be encouraged at all times
to seek clarification of information. Opportunities for one-on-one teaching and repetition of classroom teaching will be
essential for James. Presenting information visually is useful when working with James.

Educational skills were assessed with Wide Range Achievement Test -3. James has reduced reading skills; lower than
expected from initial assessment in 2000. He is unable to decode words at his age level and is likely to struggle with
increased reading demands presented in the classroom. Spelling and mathematical skills are also depressed and fall
below age expectations. Dr. Austrialis recommends formal reading intervention.

Beth Wasabi, Cognitive Specialist, Hawaii Department of Education performed an in school consultation and issued
a report on 3/20/03. Multiple recommendations are made to accommodate James’s impairments and facilitate his
learning opportunities, transition planning from elementary to middle school and high school which incorporate
recommendations made by Dr. Austrialis and Gentle, therapists and learning specialist at Denver Children’s Hospital.
Assistive technology is being considered but no particular plans are recommended.

John Doe, MD, neurologist, has evaluated James on two occasions, most recently in February 2003, although I
have not had the privilege to see the latest report. In 2001, Dr. Doe found James to have moderate to severe
hemiparesis and mild dementia as indicated by IQ testing with developmental delay in the mid-range, with moderate
expressive aphasia, severe dyslexia and inability to read. James has since started reading, though far below grade
level. Dr. Doe indicated that James would require many years of speech, occupational therapy and physical therapy,
probably all the way through his school years and probably beyond that. It is expected with interventions he would
improve but not to his previous level of IQ or motor function, and these issues would limit his vocational choices. Dr.
Doe noted James’s obesity, which he does not feel is related to James’s accident.

Upper M. Neuron, MD, Neurologist, evaluated James on 2/04/2003, and I have reviewed a draft of this report.
During this examination James denied being aware of why he was being examined, was cooperative and somewhat
disinterested. James exhibited jerk nystagmus on left gaze and rotary nystagmus on right gaze and ptosis of the right
eye. He demonstrated a right central facial paresis that disappears on smiling. He had a dense right homonymous
hemianopsia. He has slurred speech with limited speech output. He was able to remember 3 items after 5 minute
delay. James had decreased sensation on the right arm and leg with impaired light touch, temperature, vibration and
proprioception. He demonstrated severe right sided hemiparesis, with spasticity, clonus, increased right sided reflexes,
right babinski sign and a decorticate thumb on the right. Dr. Neuron summarizes the examination …”we have an
unfortunate 9 year old who has severe sequela from a traumatic brain injury. He has obvious right hemiparesis, dense
right sided loss of vision, impaired social and emotional regulation, impaired language, attention and learning and an
MRI scan confirming extensive left hemispheric damage as well as axonal shearing. These deficits are permanent and
will require lifelong supervision and medical and psychological treatment. While he may show some mild improvement
in cognitive skills over time I expect his social problems to become even more apparent and troubling as he goes into
the teenage years.”

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Thaddeus Dancer, MD, Pediatric Neurologist, evaluated James in February of 2003. Dr. Dancer noted that prior to
his injuries Jamess growth and development was felt to be progressing normally. He also noted some developmental
milestones as they were achieved by James, as below:

Developmental Milestones:
Walked 10-11 months
Words 10-11 months
Phrases 18-24 months
Toilet Trained 2 years

Examination was consistent with Dr. Neuron’s, with weight noted to be 147 lbs., height at 59 inches. Neurological
examination is notable for the following deficits: James spoke in brief phrases with very limited vocabulary. He was
only able to read very simple words from 1st grade paragraph of the Gilmore Oral Reading Paragraphs. His receptive
vocabulary was more competent than his expressive vocabulary. He required simplification of instructions and cueing
frequently. He had difficulty copying geometric figures, he wrote with his left hand. He inconsistently identified right
and left on himself and on the examiner. He was able to write his name poorly with block letters. He was unable to
write “today was a sunny day”. He took extended time to place French curve appropriately; he could only add single
digit numbers and was unable to subtract single digits. Immediate recall was 4 numbers forward and 2 numbers
backward. Delayed recall of unrelated objects was zero at 1, 3, 5 minutes. Speech was sparse and he spoke in 3-4
word phrases with marked dysarthria. There was right homonymous hemianopsia with intact vision to the left. Facial
movements were asymmetrical and there is mild flattening of the nasolabial fold and lid lag of the right eye lids.
Hearing was intact. Gag reflex is intact. Tendon reflexes were hyperactive on the right with extensor plantar response
on the right, flexor on the left. He walked with right hemiplegic gait. He wore a short brace on the right. Right upper
extremities were hyperactive with unsustained clonus at the ankle. There was little spontaneous movement in the right
hand, right fingers and he had a very weak grasp. His [right] wrist is in plantar flexion. There was a bit more
movement in the right hand and fingers when the wrist was held in extension by Dr. Dancer. With arms outstretched
and eyes closed he raised his right shoulder but was not able to hold the arm perpendicular to the body. Finger to
nose were not able to be performed on the right. He stood with a C-shaped scoliosis, concavity to the right. He had
decrease light touch and position on the right. Dr. Dancer’s impressions are notable:

1. Acquired encephalopathy with severe cerebral atrophy, history of intracerebral contusions and hemorrhage.
2. Clinical manifestations include severe cognitive deficits (mild retardation), right hemiparesis, and dysarthria,
and right homonymous hemianopsia, receptive and expressive aphasia.
3. His cognitive deficits are more severe than predicted from the IQ scores achieved on standardized testing.
4. He experiences mental fatigue and difficulty understanding material presented to him.
5. While he may graduate from high school, the graduation will not indicate he has met academic achievements
levels expected of the average student.
6. He will require special education services during his whole school career, despite such supports his
academic progress will be limited.
7. His deficits are related to the vehicle accident of 1999 and are permanent.
8. His deficits are permanent and are going to limit his ability to work at competitive employment. As a result he
will [not] be self supporting. His cognitive deficits will require he live in a supported living environment.
9. He will require guardianship as he will not be able to make the kinds of decisions that are necessary for
independent living.
10. In the future he is at high risk for the development of epilepsy.
11. His life expectancy should be consistent with other individuals of the same age who do not have handicaps.

Pediatric Physiatrist, MD, Physiatry, and Therapy team (Physical Therapy, Occupational Therapy, Speech Therapy
and Learning Specialist) have evaluated James in 2001 and in Feb 2003. Dr. Physiatrist report appears to include a
summary of his examination with rehabilitation team evaluation recommendations. The rehabilitation teams’
assessment indicates James continues to demonstrate permanent traumatic brain injury, with resultant right side
hemiparesis, right homonymous hemianopsia, and cognitive deficits including speed of processing abstract reasoning,
complex integration of verbal information, language comprehension, verbal memory, word retrieval and significant
academic learning problems. James will require continued monitoring by a Rehabilitation team. He should be seen

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yearly by a rehabilitation physician, physical therapy, occupational therapy, speech therapy, learning specialist. He will
require continued use of his AFO, which will require replacement every 18 months. He will require yearly scoliosis x-
rays and leg length scanograms until 18 years of age. James will likely require a tendoachilles lengthening as an
adolescent. He would benefit from a right upper extremity tendon transplant to improve hand function; most likely
surgery is a flexor carpi ulnaris transfer to improve wrist position. James will require continued school-based therapies
including PT, OT, and Speech [therapy]. He will benefit from OT [Occupational Therapy] for ADL, compensation
techniques and post-tendon transfer. James will require continued special education services. He is at significant risk
for academic failure; he will likely graduate [from high school] with only a participation diploma. James will require
supported employment because of the combination of physical and cognitive disabilities. James will require a guardian
to manage his affairs and resources. He will be able to live in group home or in an apartment with monitoring.

An interview was conducted by this writer with Dr. Dennis J. Physiatirst on May 19, 2003.

Summary of Deficits Identified as Arising from James’s Brain Injuries :

Cognitive and behavioral

Below average IQ, indicating mild mental retardation and developmental delay
Cognitive deficits are more severe than predicted from the IQ scores achieved on standardized testing
Global impairment of language, including receptive and expressive language
Global impairment of cognitive skills
Reduced attentional skills
Impaired attention and concentration skills
Impaired short-term memory
Impaired executive functioning
Impaired independent planning
Impaired abstract verbal reasoning
Behavioral dysinhibition
Impaired frustration tolerance
Mental fatigue

Physical

Aphasia
Globally and severely depressed language skills
Dysphagia
Dyscongugate gaze
Visual field cut right side of both eyes
Right side spatial neglect
Right side, dense hemiparesis (both upper and lower extremities)
Tonic flexion of right elbow and wrist (Posturing of right arm), associated with right hemiparesis
Difficulty with motor planning (dyscoordination), particularly fine motor planning in use of the hands
Decreased bilateral motor coordination
Visuo-constructional, visuo-motor, fine motor deficits, associated with right hemiparesis
Circumduction of gait right lower extremity w/ abduction of right hip, associated with right hemiparesis
No volitional control of distal right lower extremity muscles w/ Right foot drop, associated with right hemiparesis

Psychosocial

Anxiety
Alteration and delay in development
Unusual social behaviors (over eating, lack of control over appetite and rapid mood swings)
Impaired self awareness
At risk for impaired social development and isolation from others
Naïve understanding of the world, at risk for exploitation by peers and adults

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Current Status
At the time of injury James was 1st grader in Kona. Following discharge from rehabilitation, in April 2000, James
underwent public school educational and intellectual screening in preparation for return to school in Oahu. An
Individual Education Program (IEP) was developed for James and he returned to school part-time in special education
with one-on-one adult assistance and received out –patient physical, occupational and speech therapies. He then
attended summer school and in the fall of 2000 returned to Kona and re-entered his previous elementary school,
Kahakai, where he is continued in an IEP. Now in the 4th grade James continues in a special education class and
receives limited physical, occupational and speech therapies as well as having a one-on one instructional or
educational assistant. He is in non-academic mainstream activities such as PE (James has participated in soccer).
James’s mother transports James to school in their 1993 Honda, because the bus ride one-way to the school is one
and a half hours (1½°). The school bus takes James from school to his paternal grandmothers for after school care.
Angela K attends IEP meetings. James’s father, Jesus O, does not attend IEP meetings or other educational functions.

James is a pleasant and generally cheerful nine (9) year-old boy. James has right sided homonymous hemianopsia.
He has a dense right sided hemiplegia w/ hemiplegic gait: Circumduction, a stiff gait with toes on the right side
scraping the ground or floor due to reduced flexion of the knee and drop and swing of the hip. The right arm does not
swing with the unaffected left footstep and the right shoulder slouches. He is able to ambulate only short distances due
to fatigue and right hip soreness and pain. James is unable to use his right upper extremity and does not use the right
extremity to assist with the left unless cued. He is well groomed and particularly interested in his looks and hair, as is
age appropriate and culturally stressed. He is cooperative and possesses a sense of humor; he likes to tease and
does so in a perseverative manner consistent with deficits of his injury. James gets along well with adults and appears,
at this time, to get along well with other children. He takes simple direction well and will focus his attention when
encouraged and instructed by adults in a structured setting, such as in school. However, with more complicated
instructions or speech, or in busy environments like within the household he doesn’t seem to comprehend and is easily
distracted. He does not independently complete household chores, like taking out the garbage without repeated cuing
and is unable to take steps from the apartment if must carry object with 2 hands. When engaged in a constructive
activity and encouraged he will assist with folding/sorting laundry or putting laundry in the dryer.

James is acutely aware of how he is perceived by others and this is in conflict with his distinct desire to be “cool”. As a
result he does not like to wear prescribed glasses (corrective lenses). He enjoys being with his 14 year old brother,
Kirby, very much and wishes he could do the things that Kirby is able to do; i.e.: Kirby goes to the beach and goes
surfing. Although James would not realistically be able to surf, when he has gone to the beach is unable to keep up or
physically make the walk from condominium to the beach. If taken to the beach he has difficulty ambulating in the
sand. James’s mother indicated that prior to his injuries he was highly energetic and into mischief to draw attention.
She states he is now more subdued, as I have observed, but subject to rapid mood swings for no apparent reason. At
the primary residence, James occupies his time playing video games, playing with toys or watching TV. He does not
read or look at books alone. James is said to always be hungry and has grown obese. James’s mother is quite
concerned about his obesity and tries to limit his dietary intake; however she states she has no control over what he is
fed at his paternal grandmothers, upon whom she is dependent to provide care to James while she is working.

James’s primary residence is his maternal grandmother’s one (1) level, second story, two (2) bedroom, two (2) bath,
and condominium in a three (3) story structure. The structure is built on a hill-side and the parking lot is an inclined
blacktop surface. James lives with his mother, his older brother, Kirby, and his grandmother. James shares a bedroom
with his mother and older brother. James has a dresser for storage of clothing and personal belongings and shares a
closet with his mother and older brother. He tells me that he mainly sleeps on the couch in the main living area. This
area is where the television is located, as confirmed by his mother. No modifications for accessibility have been made
to the condominium, there is no elevator nor are there ramps. All living needs are met on same level. While James
can use a wheelchair within the apartment if necessary, there are no ramps to accommodate entry. Floor surfaces
within the apartment are wall to wall carpet and tile. Throw rugs on tile surfaces are a hazard to James, as they slip
and he has fallen on many occasions. (Apparently they have not been removed.) It is reported that there are working
smoke detectors within the apartment. James’s mother does not believe James would know what to do if there was

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afire in the home, but she states James is never alone at home. James is able to operate the cordless telephone and
has used it to call his mother at work; he phones his paternal grandmother and his cousins.

In the kitchen James can only reach items in lower cabinets and drawers. He can open the refrigerator but can only
use the lower shelves. He does not have access to upper level freezer compartment. James is said to not be allowed
to use the stove, toaster or knives. James has been burned using the toaster since his injuries. He has not been
allowed to use the stove because he “forgets if something is turned on.” He can prepare his own bowl of cereal as
long as his bowl is down from the upper cabinet and the box is opened. That is said to be the extent of his
independence within the kitchen. He is unable to reach above the counter top to obtain food stuffs, items or utensils.
James can operate the kitchen sink but cannot reach into the sink or operate the garbage disposal.

In the bathroom, James can use the bathroom mirror. His toiletries are kept on the counter top so that they are
accessible. He is able to use the bathroom sink. There are no grab bars around the toilet. While
James is continent of bowel and bladder he on occasion has accidents, and in general he is able to
perform hygiene with only his left hand. James must stand to wipe his anal area after defecation; he
states he is not able to get clean. He does independently take a shower to clean himself if he has had
an accident or feels his hygiene has been inadequate. There is a tub shower without grab bars around
or within the confines of the tub, not is there a shower bench. To get in of the tub James uses the towel
rack for balance; to get out of the tub, James uses the side of the tub for balance and swings his left
lower extremity over the side and then slides his right lower extremity out of the tub. James cannot
reach the shower head to adjust direction of spray. James is able to dress himself, although this is a
lengthy process which on average takes about 45 minutes. He can zip his pants if they are not too
tight and button his shirt, and jeans top but he cannot tie his shoes. James doe not have access or use
any assistive devices for reaching, dressing or eating.

There are laundry facilities within the apartment. Although James does assist in putting clothing into the front load
dryer, he is unable to operate top load washer or operate the dryer because the controls are at the back on top of the
machines.

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There are ten (10) steps and a landing before gaining entrance to the apartment. To climb steps James uses left foot to
attain the step and then follows with hip lift and swing (dragging) the right. When descending steps he
must lead with right hip lift and swing, holding onto the rail and follow with left. There is one hand rail
on the right side of stairs (as one climbs the stairs). James must use the left side wall with for check
balance with the left hand as he climbs the stairs. The railing is available for balance when descending
the stairs. James is unable to carry items on the stairs. There is only one entrance to the apartment.
This door swings in. The condominium structure is constructed on a hillside. There is no yard at the
condominium. There is a slanting asphalt parking lot on the uphill side of the structure. There are no
play facilities at the condominium. At this residence the responsibilities of care giving are split between
mother, older brother and maternal grandmother. At this time there is particular concern on the part of
the writer that James’s aunt, who within the last 6 months has suffered a severe brain injury with
severe impairment, is coming to live with her mother (James’s maternal grandmother) as an additional
member of the household.

James’s paternal grandmother provides after school care for James, along with 10 other grandchildren of different
ages. This home is located “5-6 miles” from his primary residence. He also spends up to 3 nights a
week in the small home of his paternal grandmother, where his father lives. This is a single unit home
on one level within a neighborhood and with a yard. No accessibility or safety accommodations have
been made for James. James does not have his own room and sleeps in the main living area where
the television is located; and, he shares this sleeping area with other members of the family. James
until recently spent most after school hours at his paternal grandmothers and in the surrounding
neighborhood, mostly playing alone, watching TV or “playing basketball” (he shoots one handed
baskets), as other children are able bodied and able to roam and play away from James within the
neighborhood. The neighborhood is said to be home of other fathers side relatives and cousins. When
allowed James’s appetite is insatiable and James’s mother states that “over there they feed him
anything he wants just to keep him quiet.”

Angela K, James’s mother, has a high school diploma. She works as a stocking clerk at and earns $8.00 per hour.
She also works at a second job merchandising independent items to area stores for commission. James’s father,
Jesus O, does not pay child support, works as an auto mechanic and lives with James’s paternal grandmother.
James’s maternal grand mother, Betty K, supports herself as a clerk at a local Walmart store.

Life Expectancy
James is thought to have normal life expectancy. The National Vital Statistics Report, Vol. 50, No. 6, March 21, 2001,
Table 2. LIFE TABLES FOR MALES: United States 1999. Pg. 9 demonstrates that a male currently between the ages
of 9 to 10 years has a remaining life expectancy of 65.7 years.

Central Observations of Life Care Plan Development

1. James has a static encephalopathy with reduction of intelligence from pre-injury status, with global
impairment of language and cognitive skills, which will result in the gap between his developmental level and
age appropriate levels widening with time.

2. The cognitive and behavioral sequela of James’s encephalopathy and developmental disabilities will dictate
his development. All future stages of growth and development (high level planning and conceptual abilities,
memory and learning) will be affected by his brain injury, reduced intelligence, impairment of language &
neuromuscular impairments.

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3. James’s brain injury has resulted in right side hemiparesis, with motor deficits of the right upper extremity
and right lower extremity which will require use of braces and orthosis. Since his brain injury James has
developed scoliosis. He is at risk for worsening scoliosis and joint contractures.

4. James has extremely poor motor control of the upper extremity. He will continue to need therapy to work on
one handed techniques. However it is likely he will require devices to assist in one handed activities but in
some functions he will likely remain dependent.

5. James is at risk for widening performance deficits as he ages and more is expected of him. James does not
have the fund of skills, habits and knowledge derived from normal growth and development to build upon in
rehabilitation and habilitation of his brain injuries. It is likely that current difficulties will persist and that
deficits will emerge as new skills (age appropriate) fail to develop appropriately.

6. James has poor attention and concentrations skills, along with impaired judgment and these deficits are likely
to persist. James will require adequate parental and childcare supports throughout the maturation process.

7. For the remainder of his life James is at risk of secondary injury. These risks are the result of right side visual
field cut, right side neglect, hearing impairment, poor attention and concentration skills, impulsiveness and
lack of safety awareness.

8. The nature and severity of James’s injuries indicate he will experience serious residual functional difficulties.

9. James condition will have a substantial & lifelong impact on the nature and quality of his life and those of his
family.

10. There is a very great possibility that James will fail to develop adequate independent life skills, be unable to
complete his education or obtain gainful employment and require ongoing support in domestic and financial
domains.

11. The outcome of James’ brain injury can be tempered by appropriate and ongoing rehabilitation.

12. James will require customized educational programming with careful structure, as well as careful monitoring
of learning capacity and to compensate for cognitive processing and attentional deficits.

13. As James ages into adolescence and adulthood, cognitive, language and behavioral impairments will effect
and compound his chances for injury, and psychological, social, and financial distress.

14. James is at risk for behavioral problems that may require intensive programming. Behavioral control and
management will need to be a focus of rehabilitation, habilitation and socialization.

15. James is at risk for ongoing obesity and will require regular exercise as well as nutritional counseling and
restrictions to prevent health problems associated with obesity.

16. The family is the one constant in James’s life while the service systems and support personnel within the
James’s health care system will fluctuate.

17. Disruption in the lifestyle and the emotional strain on the family, caused by James’s brain injury, result in
complex, long-standing problems.

18. Failure to anticipate family dynamics and needs and not provide appropriate interventions is likely to limit
potential success of any rehabilitation or habilitation plan or program. New skills are needed by the family to
meet the ongoing challenges created by brain injury.

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19. No person or family is completely or ever prepared for the personalized reality of a brain injury experience.
James’s brain injury changes the family and challenges its resources; brain injury brings out the best and the
worst in people and in families; and not all families are capable of responding to the needs of a brain injured
family member. Prolonged use of maladaptive coping strategies and persistent feelings of helplessness are
related to confusion, marital conflict, and parental overprotection or inconsistencies,

20. Respite care should be available to James’s family and future caregivers.

21. James will require a case manager to coordinate educational and rehabilitation needs in to the future; and a
case manager will be required for coordination of health care, care givers, supported living through transition
to adulthood and thereafter. The needs for case management will be variable as will the level of assistance.

22. James’s progress will require careful monitoring over the next several years, to identify new and persisting
deficits and to provide support for James and his family as James moves through developmental transitions.

23. James is at risk for academic failure due to learning deficits. James is participating in an Individual
Educational Program through the Kona School District. James will require a supplemental aid and support
throughout his educational experience, as well as regular physical therapy, occupational therapy, speech
therapy and social services interventions through an individualized educational program and special
education.

24. James is at risk for limited success in school with a negative impact on his ability to lead a fully functional
adult life. Later in James’s educational experience he will benefit from employability training and transition to
adult services, including life skills training.

25. James requires a stable living environment that allows for structure and consistency, accessibility and safety,
as well as room for play and recreation, and later a living space for care givers.

26. James will outlive his mother and requires a plan that provides continued supervision and care in living.
James will likely live in his family home through his majority. He will require continuous supervised living with
reasonable support systems, but not necessarily require sheltered, group or foster living arrangements.

27. Despite this pervasive and often dire prognosis, James can learn and thrive in a supportive environment.
James will require close supervision but will likely enjoy some level of independence and satisfaction in life’s
achievements. James is capable of inclusive community living in the environment of his choice with
appropriate supports.

28. It is reasonable to assume James is capable of a quality of life that allows for a sense of home in a personal
living situation, with sense of security, personal control and choice; and relationships, particularly those that
are non-paid, work and/or other meaningful pursuits.

29. Personal control and choice within in the community are central to a quality of life and they are particularly
important for those persons, like James, with the most severe disabilities. This includes control and choice
across all aspects of their lives, where and with whom they live, who provides support, relationships, work
and pursuit of other interests.

30. Exercising control and choice is a process not a one-time event. James will require assistance and
guidance.

31. James will be capable of employment in a sheltered workshop or in supported employment.

32. Relationships are an essential aspect of community life. Support is not just about activities, but is equally
about presence, trusting relationships, and interconnections. Therefore it is important that support persons
assist in the development of positive relationships with James.

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33. Cognitive deficits, impaired judgment and executive function impairment may never allow James to manage
his own finances. A life long system of guardians, conservators and case managers will need to be
established to meet his needs and for his protection.

34. It is probable that James will not operate a motor vehicle and he will be dependent for transportation, though
he may learn to arrange for transportation or to some extent utilize public transportation should this become
available in his home area.

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Needs
A summary of annual costs by modality is provided in a separate report attached to this document.

Evaluations
Orthopedic 1
James has contractures of the right hip, and ankle and non-functional right upper extremity which interfere with his
independent function. He is having a great deal of pain and discomfort and loss of function in the right hip. He is
developing a scoliosis. James will require long-term management of orthopedic problems to follow the effects of his
right sided hemiplegia on physiologic function and on skills for independent living. James will need to be evaluated
annually until skeletally mature and then every 2 years through age 30, then every 5 years through age 60, and then
return to every 2 years through remainder of life expectancy.

Cost $ 153 Recommended by

Annual $ 153, thru age 18 Pediatric Physiatrist, MD
Cost $ 153 every 2 years thru age 30
$ 153 every 5 years age 31-60
$ 153 every 2 years beginning age 60
thru LE

Physiatrist (PM/R) 2
James’s primary care physician has stated that he will continue to treat James for regular childhood needs, he will not
be evaluating and treating James for issues and conditions surrounding his brain injury unless upon recommendations
of Physiatrist and other specialists. It is recommended that James be seen at least one time per year by a pediatric
Physiatrist. There are no pediatric Physiatrists in Hawaii. Dr. Physiatrist has agreed to become James’s treating
Physiatrist. James has been seen 2 times (2001 and 2003) by Dr. Physiatrist at Denver Children’s Hospital. Dr.
Physiatrist states that James should be seen one time a year through maturity in conjunction with interdisciplinary
rehabilitation therapists through maturity and then yearly thereafter. After age 21 his PM/R care may be assumed by
Physiatrist in the islands with experience evaluating and treating brain injured persons.

Cost $ 478 with team conference Recommended by

Annual $ 478, thru 2012 Pediatric Physiatrist, MD
Cost $ 256, thru life expectancy

Ophthalmologist 3
James should be evaluated annually by neuroopthalmologist due to right homonymous hemianopsia and vision
correction needs.

Cost $ 182 in 2003 Recommended by

Pediatric Physiatrist, MD

Neurosurgeon 4
James has not seen a neurosurgeon since his discharge from acute rehabilitation care. Due to skull flap he will be
evaluated as he approaches skeletal maturity to determine whether further cranioplasty is necessary.

Cost $ 153, 1 time in at age 14, 2008 Recommended by

Pediatric Physiatrist, MD

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Physical Therapy 5
James has right hemiparesis and gait related difficulties, joint contractures, poor balance, and is developing scoliosis.
James will require physical therapy evaluations for recommendations regarding orthotics, home exercise & stretching
programs, and consultation for in school physical therapy. After age 18-21 James will continue to require orthotics and
have difficulties related to hemiparesis. James is at risk for deconditioning and deterioration of functional abilities.
Physical therapy evaluations are to transpire annually until skeletal maturity, age 18, in conjunction with physiatry and
multidisciplinary evaluations at Children’s Hospital. Thereafter, evaluation should occur every 2 years.

Cost $ 126 / hour Recommended by

Annual $ 252, with conference thru age 18 Pediatric Physiatrist, MD
Cost $ 63, age 19 thru life expectancy

Occupational Therapy 6
With right hemiparesis and right upper extremity related difficulties, joint contractures and cognitive deficits James will
require occupational evaluations for recommendations regarding activities of daily living, orthotics, home exercise &
stretching programs, and consultation for in school occupational therapy. After age 18-21 James will continue to
require orthotics and have difficulties related to hemiparesis and activities of daily living. James is at risk for
deterioration of skills depending on challenges in his environment. Occupational Therapy evaluations are to transpire
annually in conjunction with physiatry and multidisciplinary evaluations at Children’s Hospital, until James leaves the
public school system, age 21. The occupational therapist will monitor independent function, implement and supervise
a home therapy program and prescribe appropriate daily living equipment and assist with in-home computer set up and
use. As an adult James will meet many transitions in which the occupational therapist will be instrumental in assessing
compensatory strategies and equipment. James will require annual evaluations through age 22 and then every 1-2
years as necessary throughout life expectancy.

Cost $ 126 / hour Recommended by

$ 252, with conference thru age 18 Pediatric Physiatrist, MD
$ 126, age 22 thru life expectancy

Speech and Language Pathology 7

James has been receiving speech therapy through public schools and IEP on limited basis. Maintaining an effective
program of therapy within the schools will require evaluation of James’s physical and developmental capabilities and to
set achievable goals that are obtainable within his limitations; this will contribute most to his public school program
design and overall communication effectiveness. James will require a combination of expressive speech, receptive
speech therapies to be used within the public school IEP, as well as augmentative use of computer to facilitate written
work and communication. James will participate in annual evaluations with speech and language therapy with
interdisciplinary evaluations at Children’s Hospital through age 18.

Cost $ 347 with team conference thru age 18 Recommended by

Pediatric Physiatrist, MD

Educational / Learning Specialist 8

With cognitive deficits, developmental delay, language difficulties James will require annual evaluation of Learning &
Educational specialist in conjunction with interdisciplinary team evaluation at Children’s Hospital and Physiatry
evaluation. The purpose of the evaluation is to assess development between annual assessments and utilize
recommendations of physician’s, psychologist and other therapists to formulate the best possible compensatory plan
and provide consultation and strategies to the public school individual education program. In addition to objective
evaluation, the specialist serves as advocate for James and his family within the special education process.

Cost $ 437 with team conference Recommended by

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 $ 437 thru age 18 Pediatric Physiatrist, MD

Neuropsychological Evaluation 9
James has received neuropsychological evaluation in 2001 and 2003, though he has not had the benefit of
neuropsychological evaluation as part of interdisciplinary team evaluation. Purpose of neuropsychological
assessments are diagnosis the nature of brain function but also assessment behavioral aspects of brain function to
identify and implement effective management, rehabilitation, or remediation services. Dr. Physiatrist has
recommended continued neuropsychological assessment in conjunction with interdisciplinary evaluations at Children’s
Hospital. Dr. Louis will direct and coordinate interdisciplinary team neuropsychological evaluations and recommends
full neuropsychological batteries in years James is meeting transitions (see years below). During annual assessments
Dr. Louis will serve role as rehabilitation psychologist in recommendations to treating physicians, schools, family,
caregivers and case manager.

Cost Recommended by
Annual Costs $ 1,356 in 2004, 2006, 2008, 2009, 2011, Pediatric Physiatrist, MD
2013 Jane Louis, PhD
$ $2,500 in 2005, 2007, 2010, 2012, 2014

James will likely require ongoing intermittent neuropsychological evaluations with additional transitions into supported
independent living and adjustment to job or avocational changes. As such these evaluations will also serve to provide
rehabilitation psychology evaluation with recommendations to treating physicians, caregivers, vocational providers and
case manager These evaluations can utilized to best support James’s modified independence and address behavioral
aspects of his performance or remediation of performance.

Cost $ 1,356 in 2017, and estimated for 2030 Recommended by

Pediatric Physiatrist, MD
Jane Louis, PhD

Behavioral Psychological Evaluation 10

As James ages into adolescence and adulthood, cognitive, language and behavioral impairments will effect and
compound his chances for injury, and psychological, social, and financial distress. James is at risk for behavioral
problems that may require intensive programming. Behavioral control and management will need to be a focus of
rehabilitation, habilitation and socialization. James has poor attention and concentrations skills, along with impaired
judgment and, these deficits are likely to persist. James will require adequate parental and childcare supports
throughout the maturation process and these will include consistent behavioral approach to James’s care and
behavior. It is recommended that James will require intermittent behavioral psychological evaluation for programming
to be used for James’s insight and use by caregivers and family with environmental changes and to aide in educational
interventions. It is probable that James will require behavioral intervention at least twice as a young adult.

Cost $ 642, in 2005 Recommended by

$ 817, in 2008, 2012, 2015 to be coordinated Pediatric Physiatrist, MD
in local environment Jane Louis, PhD
$ 933, in 2007, 2009,2010, 2011, 2013, 2014
to be part of interdisciplinary
neuropsychological evaluations at
Children’s Hospital

Dietary /Nutritional Evaluation 11

James is above the 90th percentile in growth and mother and treatment providers have concerns regarding his obesity.
He gained 33 pounds in a 6 month period between August and 2002 and February 2003. There are behavioral issues
regarding his awareness of appetite and satiation. In addition familial obesity is a problem. With limited mobility James

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and his mother have been unable to limit a caloric intake to caloric need. These evaluations will assist the family and
caregivers in managing appropriate nutrition and dietary intake in conjunction with behavioral programming. Regular
evaluation is recommended until age 21 in conjunction with interdisciplinary team evaluations at Children’s Hospital. It
is anticipated that James will also require assessments at least 2 times as a young adult for who estimated dates are
offered.

Cost $ 173, / yr. thru age 21 Recommended by

$ 173, in 2017 & 2029 Pediatric Physiatrist, MD

Medical Care
Medical Care recommendations for medical and surgical care are identified as expected particular to James’s
condition, considering factors which influence its condition.

Primary Pediatrician/Internal Medicine Physician 12

James has primary pediatrician Dr. Walter Sugar, whom he has seen regularly for normal childhood medical care.
Following his injuries, James will continue to require normal childhood care, and as and adult James will continue to
require normal medical surveillance and care; however, he will have increased need for surveillance and care for
issues secondary to his physical and cognitive deficits. It is recommended that James have at least one medical visit
with primary care physician in addition to normal annual evaluation.

Cost $ 110 1 X / yr. through life expectancy Recommended by

Pediatric Physiatrist, MD

Physiatrist/PM/R 13
James has been seen intermittently by a Pediatric Physiatrist but there is no longer a Pediatric Physiatrist in practice
in state of Hawaii. James has most recently been evaluated by Dr. Pediatric Physiatrist, and Dr. Physiatrist has agreed
to become James’ treating Physiatrist, consulting with Dr. Sugar and other physician specialists in James’ rehabilitation
care. It is recommended that James be evaluated for treatment of various conditions resulting from his brain injury at
least yearly through childhood and adolescence. As an adult, James will receive care from an adult Physiatrist in the
state of Hawaii who has experienced in treating and evaluating persons with brain injury, every 2 years or more
frequently as is necessary.

Cost $ Cost is attributed to interdisciplinary Recommended by

evaluation at Children’s hospital through Pediatric Physiatrist, MD
childhood and adolescence (2003-2014)
$ 177, in 2015
$ 88, in subsequent years thru LE

Neuro-ophthalmologist/Ophthalmologist 14
James has been evaluated by an optometrist, but has not had ongoing medical eye care specific to his hemianopsia
and other brain injury related vision deficits. James currently has prescribed corrective lenses, and has lost his glasses
in the past requiring replacement. Examination of James will require more time by the treating physician than with a
person without brain injury

Cost $ 110, 1 X / yr. 2004-LE Recommended by

Pediatric Physiatrist, MD

Neurologist
While receiving physiatry care it is not necessary that James receive care from a neurologist unless he should develop
seizure disorder or develop an unknown neurological condition. While receiving physiatry care neurology will be a

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duplicate service. In the event that James experiences seizures or neurological deterioration he will be referred to a
neurologist or neurosurgeon.

Cost $ 0, need is not predictable at this time Recommended by

Pediatric Physiatrist, MD

Orthopedic Surgeon 15
James has been receiving ongoing orthopedic evaluation and treatment, in the form of prescription of therapies and
orthotics. James’s right sided hemiplegia has wide effect in right upper and lower extremity, along with need for
monitoring scoliosis. James will require frequent monitoring of right upper extremity and will require tendon transfer
procedure in the right wrist and hand. James is experiencing hip contracture that is interfering with independent
function at this time and is being evaluated for surgery (results are unknown at the time of this writing). James is a risk
of leg length discrepancy with need of leg lengthening procedure, severe contracture of the right hip and right ankle
with need for contracture release in the right hip and tendon lengthening in ankle. Over time and with aging James is
at very high risk to develop arthritis due to over use as well as in joints affected with paralysis due to hemiplegia.
James will require 2 orthopedic physician visits per year through age 18; then he will require one (1) orthopedic
physician visit per year through life expectancy.

Cost $ 109 / visit Recommended by

$ 109 in 2003 Pediatric Physiatrist, MD
$ 218, in 2004 and subsequent years until
2012
$ 109 in 2013 thru life expectancy

Orthotist 16
James currently is receiving his orthotics from therapists and orthotist for fabrication of specific dynamic AFO. James
will continue to be required to wear orthotic devices on the upper extremity as well and the lower extremity due to right
sided hemiplegia. He will require regular visits to the orthotist for provision of new orthotics, due to growth, damage
and/or adjustments. These are twice annual visits through age 18 then annual through life expectancy for fitting,
adjustments to devices, as well as provision of new orthotics.

Cost $ 153, base cost (3 Units=45 minutes) Recommended by

$ 153, 2003 Pediatric Physiatrist, MD
$ 306, 2004-2012
$ 153, 2013-LE

Diagnostic Testing

Recommended diagnostic procedures and tests are related to James’s condition in order to monitor progress or risk for
potential complications. Diagnostic studies are utilized to determine appropriate course of treatment and evaluate
outcomes of interventions. James has received monitoring of scoliosis and contractures secondary of right sided
hemiparesis. Dr. Physiatrist has recommended the following diagnostic tests as medically necessary secondary to
James’s condition, and indicated the frequency of testing.

Diagnostic Test Frequency Age of Occurrence Base Cost Annual Cost Life Time Cost
(thru age of
occurrence)
Magnetic Resonance17 1X Age 17 (2011) $1,997 $1,997
Imaging – Head/Brain
Cervical Spine X-ray18 Annually Thru age 18 (2003- $315 $315 $2,835
2012)

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Thoracolumbar X-ray Annually Thru age 18 (2003- $161 $161 $1,449
(scoliosis survey) 19 2012)
Right hip X-rays20 Annually thru Thru age 18 (2003- $179 $179 $1,449
2012 then 2012). As adult ages
intermittently as an are unknown.
adult
Right ankle & foot X-rays21 Annually and Thru age 18, in $220 $220 $2200
epiphyadesis 2007 2 X-rays Pre &
Post operatively w/
right lower extremity
Leg Length scanograms22 Annually Thru age 18 (2003- $207 $207 $1,863
2012)
Educational Testing Annually, Thru age 20 (2003- (covered in
performed w/ 2014) evaluations)
interdisciplinary
evaluations
Vocational Testing, augment 1X Age 20-21 (2014- $600 $600
transitional public school 2015)
services23

Therapeutic Modalities
Physical Therapy 24
James is currently receiving physical therapy in context of public education and through IEP for approximately 30
minutes per week. Physical therapy outside of school is recommended 1 X per week through age 12 for activities
associated with functional and avocational activities after school, as well as supplemental therapy in conjunction to
school therapies. After age 12 James will receive physical therapy 1 X per month for monitoring and implementation of
new skills, home exercise and stretching program, and consultation with school program. James will require 6-10
sessions around surgeries for hip and tendoachilles contracture release, and epiphyadesis surgeries and then return to
weekly maintenance & intervention schedule when applicable. Contracture releases may require repeat procedures
despite ideal home programs. If this should occur then post operative physical therapy is indicated at those unknown
future dates (listed under complications).

Cost $ 107 session weekly routine schedule, 48 Recommended by

weeks per year 2003 -2006 Pediatric Physiatrist, MD
$ 107 session, 1 X / month thru age 21
(2007-2015)
$ 160 10 sessions, 2003 for hip release
$ 160 10 sessions, 2004 tendoachilles
release
$ 160 10 sessions, 2007 epiphyadesis

Occupational Therapy 25
James is currently receiving occupational therapy in context of public education and through IEP for approximately 30
minutes per week. Occupational therapy outside of school is recommended 1 X per week through age 12 for activities
after school associated with activities of daily living, compensatory strategies, care giver training, as well as
supplemental therapy in conjunction to school therapies. After age 12, through age 21, James will receive
occupational therapy 1 X per month for monitoring and implementation of new skills, consultation with school program.
Will require 6-10 sessions post-operatively following wrist tendon transfer (flexor carpi ulnaris transfer) surgery for
surgeries and then return to weekly maintenance & intervention schedule when applicable.

Cost $ 107, / session, weekly (48 weeks/ yr.) 2003- Recommended by

2006
$ 160 for 10 sessions post-operatively 2004 Pediatric Physiatrist, MD

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 $ 107, 1 session / month thru age 21 (2007-
2015)

Speech & Language Therapy 26

James is currently receiving speech therapy in context of public education and through IEP for approximately 30
minutes per week. Speech therapy outside of school is recommended 1 X per week through age 12 for activities
associated with functional and avocational activities after school, cognitive therapy, use of in-home computer and
cognitive, speech exercises, as well as supplemental therapy in conjunction to school therapies and care giver
training/monitoring. After age 12, through age 21, James will receive occupational therapy 1 X per month for
monitoring and implementation of new skills, consultation with school program.

Cost $ 153, per weekly session thru age 12 (48 weeks / Recommended by
yr. 2003-2006) Pediatric Physiatrist, MD
$ 153, per session 1 X per month thru age 21
(2007-2015)

Psychosocial Support
Recommendations are made for psychosocial interventions to support the health status of the individual caregivers at
key periods of transition and stress. Activities in which the James is able to participate with others having a similar
condition or of a similar level of function support his and his caregiver’s psychosocial status.

Family Counseling 27
James and his family have not and are not currently receiving counseling. The effects of severe traumatic brain injury
to child have great effects on the family. James’s family is at risk due to premorbid level of function, financial resources
of the family and the fact that James was in the care of his mother at the time of injury. Significant behavioral
challenges can be expected to occur as James ages, family adjustment issues will require addressing. James also
requires assistance from family and parents to regulate behaviors and to be very clear of his behavioral limits and
expectations are, in a way that is productive for him. Family and caregivers must provide appropriate behavioral limits
and expectations. Recommendations are made for psychosocial interventions to support the health status of the
individual caregivers at key periods of transition and stress.

Cost $ 175, 4 X’s / yr. thru age 21 Recommended by

Pediatric Physiatrist, MD
Aurora Austrialis, PhD
William Dancer, MD

Behavioral Psychologist 28

In order to function in the real world a person must have the same social skills that other persons have. Dealing with
behavioral and socialization are not being dealt with in a way that is going to be productive for James and in the future
it is probable that his behavior will be very challenging. James is impulsive with less insight than others. He is going to
need guidance that others might not require. Behavioral psychologist will provide family and caregivers appropriate
behavioral limits, expectations and a means to achieve those goals, for James’s safety and that of the public. James
has yet to receive any behavioral programming or analysis short of neuropsychological evaluations.

Cost $ 120 per session Recommended by

$ 480, 2003-2007, 4 sessions/ yr. Pediatric Physiatrist, MD
$ 480, 2008, 2012, 2015 – 4 sessions/yr. William Dancer, MD
$ 360, 2009, 2010, 2011, 2013, 2014
$ 480, 2015 and every 2 years until age 30 –
2024

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- 23 -
Brain Injury Association of Hawaii 29
Membership in the brain injury association and participation in support group activities with others having a similar
condition or of a similar level of function also support his and his caregiver’s psychosocial status. Brain injury
association also provides support and resources for family members.

Cost $ 50 / yr. membership thru LE Recommended by

Wayne Eklund, RN
Pediatric Physiatrist, MD

Special Olympics

Cost $ 0 / thru LE Recommended by

Wayne Eklund, RN
Pediatric Physiatrist, MD

County Parks & Recreation 30

James enjoys participatory sports. He has played soccer in the past and enjoys this activity. Other participatory sports
and activities become available as James gets into adolescence.

Cost $ 30 / yr. annual fee 2004 thru 2014 Recommended by

Wayne Eklund, RN

Kona YMCA 31
Family membership while James is a minor allows for family participation in activities and swimming. As an adult
James may participate in a variety of events for community inclusion, exercise and recreation and informal adult
guidance.

Cost $ 90 / month family membership thru 2015 Recommended by

$ 47 / month single membership 2016 thru LE Wayne Eklund, RN

Future Procedures
Tendoachilles Lengthening 32
James has experienced contracture of the right tendoachilles tendon (Achilles tendon) due to right sided hemiplegia.
Contractures continue to occur despite stretching and use of ankle foot orthosis. The tendoachilles will require
lengthening at approximately age 13 and is therefore provided within this plan. It is not unusual that more than one
procedure is required over an individual’s lifetime; however, this cannot be predicted at this time.

Cost $ 1,435, surgeons fee Recommended by

$ 200, anesthesia fee Pediatric Physiatrist, MD
$ 365, assistants fee
$ 6,170, hospital charges
Total $ 8,170 in 2007
Cost
Flexor Carpi Ulnaris Tendon Transfer 33
James’s right wrist and hand is non-functional as result of his brain injury and dense right sided hemiplegia. James’s
right hand is closed onto itself and remains moist allowing for fungal growth, and presents risk for future skin break
down of the hand. In order for James’s right upper extremity to become more of a functional assistance and to allow
for adequate hygiene of the right hand it is recommended that he undergo flexor tendon transfer in the right wrist and

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hand. This procedure will place James’s wrist and hand in a more functional cocked-up position and provide for easier
skin care of the fingers and hand. It is recommended that James receive this procedure within the year in order to
maximize practice of compensatory techniques in use of the hand as a gross assist.

Cost $ 2,043, surgeons fee Recommended by

$ 404, anesthesia fee Pediatric Physiatrist, MD
$ 407, assistants fee
$ 4,500, hospital charges
Total $ 7,354 in 2004
Cost

Potential Complications
Potential complications are indicated for consideration in treatment of a James’s conditions; however, associated costs
are not identified but may be estimated. The recommendations in this plan support the delivery of care with adequate
monitoring and essential interventions in order to decrease or eliminate the occurrence of complications that can occur,
but for which efforts are implemented to prevent include:

Potential Complications Discussion Est. Cost If

Available

Seizures, Seizure Disorder
Right upper extremity
contractures
Scoliosis
Lower Extremity Contractures
Joints stress on Joints and Spine
with subsequent arthritis
While there is high degree of medical possibility that James Unknown
could develop seizures 2° to the brain injuries he sustained,
that probability is less than 50%
James has a flaccid right upper extremity without muscular Cost is
control. Mild contractures will actually be beneficial to allow for provided in
steadying and balancing of objects using right upper extremity procedure
in gross assist. (above)
Proposed flexor carp ulnaris tendon transfer is to affect a mild
contraction at the wrist to allow for wrist to cock up, thereby
opening the hand and fingers into more anatomically functional
position.
Home exercise program is currently poorly carried out and Unknown,
Physical therapy is for educational model. Additional therapies
with monitoring of home program will help to prevent scoliosis
from worsening. If scoliosis worsens may require additional
physical therapy to use of TLSO (Thoracolumbosacral orthosis)
or surgical correction with extensive hospitalization and
therapies.
Currently has significant right hip contracture and tendoachilles Unknown
contracture with some inversion of right foot. James is currently
having severe pain and discomfort and loss of function in right
hip and undergoing evaluation for possible release procedure
All of the weight on the right weakened side James with daily Unknown
walking and activities amounts to cumulative joint stress he is at
risk for arthritis in knees, right hip, and in right shoulder and
wrist, and over use of the left shoulder and left elbow and wrist.
Treatment would likely entail additional physical and
occupational therapy and eventually the use of non-steroidal
anti-inflammatory medications ranging from relatively
inexpensive multi-dose medications such as Ibuprofen, to more
expensive single daily dose anti-inflammatory agents. James

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Falls and 2°brain injury
Obesity and secondary health
related problems including
cardiopulmonary deconditioning
Falls and accidents resulting in
orthopedic injury
Behavioral dyscontrol
will also require the use of wheelchair and scooter as stressed
and over used joints make walking too painful and fatiguing an
experience for longer distances and eventually for shorter
distances, even within the home.
Balance deficits secondary to hemiplegia and hemianopsia in Unknown
conjunction with cognitive behavioral deficits allow for frequent
falls. Possibility of secondary brain injury is exponential with
any future head trauma
Cognitive deficits and poor appetite regulation versus anxiety Unknown
and depression or poor familial dietary intake monitoring have
resulted in an insatiable appetite and moderate to severe
obesity for age. Frequent assessment and use of case
manager and attendant care should increase exercise and
regulate caloric intake during those hours. Monitoring is in
place with live care plan.
Plan has provided for assistive devices for mobility; however Unknown
cognitive deficits, including impulsiveness and hemianopsia
increase the likelihood that James will sustain significant falls or
other trauma resulting significant musculoskeletal injury
James is expected to have future problems with impulse control
and emotional control associated with problems of older
adolescents perceived as having dangerous implications. For
behavioral dyscontrol and example of medications used for (Risperdal)
treating such conditions range from Tegretol to Risperdal $1,032 / yr.
Medication for improving and maintaining attention and (Ritalin) $30-
concentration, example Ritalin. $60 / month
For depression James would potentially require an (Celexa)
antidepressant, Celexa, as an excellent example $864 / yr.
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Equipment / Supplies
Equipment is selected for James with emphasis on maintaining physiologic function, preventing complications, and
facilitating care. Equipment replacement schedules take into account rapid size changes due to normal growth in
childhood. The current regimen serves as a basis for the supplies and medications identified. This is considered in
projecting future costs.

Equipment Frequency Period of Base Annual Life Time

Occurrence Cost or Cost Cost
Initial (thru age of
occurrence)
Cost
Pediatric, plastic, base utensil holder34 Every 2 years 2003 -2006 $11 $11 $33
Pediatric, plastic, base utensil holder35 Every 2 years 2008-LE $12 $12 $384
Weighted base for utensil holder36 Every year 2003-LE $13 $13 $871
Attachable pointer for computer use37 Every 3 years 2003-LE $18 $6 $414
Long Handle Scrubber38 Every 5 years 2003 -LE $25 $5 $325
Suction Brush39 Purchase 2, replace 1 2003-LE $12 $6 $210
every 2 years
One Handed Pairing Board40 Every 5 years 2010-LE $52 $10.40 $260
Even Slicer w/ knife41 Every 5 years 2010-LE $60 $12 $300
Clamp-on Peeler42 Every 10 years 2010-LE $26 $2.60 $130
Under Cabinet Opener43 Every 7 years 2004-LE $9 $1.29 $72
Sure Hand Button Hook44 Purchase 3, replace 1 2003-LE $21 $7 $483
every year
Dressing Stick w/ Shoe Horn45 Every 3 years 2003-LE $12 $4 $264
Spirolaces46 Purchase 4 pair, 2003-LE $20 $10 $410
replace 2 each year
Nail Clipper/Static File47 Every 7 years 2003-LE $25 $3.58 $250
One Hand Can Opener48 Every 10 years 2014-LE $41 $4.10 $246
Toothpaste Dispenser49 Every 6 years 2003-LE $23 $3.83 $322
Twixit Clips (one handed bag sealers)50 Every 2 years 2003-LE $9 $4.50 $297
Dycem (roll)51 Every 10 years 2003-LE $143 $14.30 $858
Folding Pan Holder52 Purchase 2, replace 1 2010-LE $30 $3 $195
every 5 years
Food Processor53 Every 10 years 2010-LE $230 $23 $1,380
Lever Door Handles54 5 for current residence, 2003 $65 $65
1 X purchase
Ergonomic Cookware Set55 Every 7 years 2010-LE $130 $18.57 $1,170
Computer (LT), w/ left hand mouse56 Every 5 years 2003-LE $950 $190 $8,939
Computer Printer57 Every 7 years 2003-LE $218 $31.14 $2,180
Folding Cane58 Annually 2003-2010 $30 $30 $240
Replacement Schedule Every 2 years 2011-2016 $30 $18 $90
Replacement Schedule Every 5 years 2017-LE $30 $6.77 $300
Wheeled Walker59 Every 10 years 2050 $130 $13 $390
Parts Replacement60 Every 2 years 2052 $70 $33 $560
Cane and Walker Tips61 3 per year 2003 $4 $12 $804
Handi-Pac Carry All62 Every 10 years 2050 $28 $2 $56

Bath Bench63 2 X during LE 2003 $72 $72

Total Costs-Equipment $2,477 $511 $23,020

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Wheelchair 64 and Maintenance 65
James is currently able to walk; however he is experiencing pain and discomfort in the right hip with walking and is
currently being evaluated for surgical release of right hip contracture related pain (records are not yet available
regarding this issue.) James will require wheelchair use for mobility following this procedure and a rental chair is in
order; however, it is more cost effective to purchase a folding chair for long term use due to anticipated procedures and
the need for mobility over longer distances during which James may easy be pushed by a caregiver, education
assistant, etc.. James also experiences extreme fatigue with walking any significant distances or as day progresses
and his gait deteriorates. It is recommended that James have available for use a light weight wheelchair for use in
home and with in a few years (2007) a scooter for use when the need is to travel longer distances.

Cost $ 1,170 base cost, every 5 years 2003 thru LE Recommended by

James will use an adjustable and folding Pediatric Physiatrist, MD
light weight chair to accommodate his size Wayne Eklund, RN
weight through the life span. Quickie 2® is
fully adjustable, folds for ease of
transportation, has removable footrests for
scooting about in home, classroom or
office. Variable seat dimensions for
custom fit w/o special orders or additional
costs. Accommodates current weight up to
350 lbs in this model.
$ 150, vendor estimated annual repair and
parts cost (Ex: 2004-2007, 2009-2012)

Scooter 66 and Maintenance 67

As James reaches greater level of maturity, an electric scooter is appropriate for longer distance in community mobility.
A 4-wheeled scooter, Pride Hurricane®, is recommended for greater stability on uneven surfaces due to James’s poor
balance. An in scooter battery charging system is recommended. Battery life is approximately 2 years with
appropriate maintenance charging. There is 3 year warranty for parts and labor.

Cost $ 3,450 every 5 years, 2007-2027 Recommended by

$ 3,450 every 7 years, 2027-LE Pediatric Physiatrist, MD
$ 170, battery replacement; schedule Wayne Eklund, RN
(Ex: 2009, 2011, 2012-Scooter
Replacement, 2014, 2016, etc.)
$ 100-150 per year for repair and tires,
bearings each following warranty
expiration.

Orthotics
Dynamic Ankle Foot Orthosis 68
James is dependent on right dynamic ankle foot orthosis and will be dependent upon this orthosis for the remainder of
his life. Impulsiveness, weight and unique gait will require frequent replacement while a youth. The usual pattern is
that as individual passes from youth to young adult with skeletal maturation and relative maturation, the replacement
frequency decreases.

Cost $ 798, base cost Recommended by

$ 798, every yr. 2003-2013 Pediatric Physiatrist, MD
$ 798, every 18 months, 2014-LE

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Resting Hand Splint 69
James has been dependent on resting hand splint since his injury. His right upper extremity is basically non-functional.
The splint is donned for two (2) hours on, two hours off, while he is awake. With frequent donning and storing, James
has managed to lose several of these splints. They are specially fabricated to fit. He will require frequent replacement
through skeletal maturity (age 18) and with changes in weight and hand volume should obesity trend continue. He will
require replacement annually through 2020 and then replacement every 18 months through life expectancy.

Cost $ 366, 2004 through 2014 Recommended by

$ 366, 2014every 18 months thru LE Pediatric Physiatrist, MD

Action/Cock-up Wrist Splint 70

James also has non-functional right upper extremity with extremely poor muscle control and hyperactive reflexes and
some neurologic posturing. For more functional use of the right upper extremity as a gross assist James is provided a
cock-up wrist splint. Following tendon transfer in the wrist he will continue to require use of cock-up splint to assist in
maintenance of anatomic posture of the right wrist and hand for greater functional use. With frequent donning and
storing, James has managed to lose several of these splints. They are specially fabricated to fit. He will require
frequent replacement through skeletal maturity (age 18) and with changes in weight and hand volume should obesity
trend continue. He will require replacement annually through 2020 and then replacement every 18 months through life
expectancy.

Cost $ 86, 2003-2014 Recommended by

$ 86, 2014 every 18 months thru LE Pediatric Physiatrist, MD

Medications
At this time James is not taking any prescribed or over the counter medications. It is probable that James will require
medication to assist in improving and maintaining attention and concentration or behavioral control in the future, or to
combat depression. However at this time it is not possible to determine which condition or problem will manifest itself
to the level to require medication for control. Examples of medications and associated costs are provided in
Complications section of this report.

Educational / Vocational
Education
James is a student in public education in his home community. While James’s pre-injury developmental progress and
cognitive abilities were age appropriate, following the injury in question James’s test scores and behavior indicate he
has lost significant intelligence quotient points and acquired scattered severe cognitive deficits and now falls into range
of mild retardation. He is attending school under and Individualized Education Plan and receiving special education
under PL-142 and IDEA. James attends summer school. James receives transportation to and from school through
busing and receives individual tutoring and individual assistance through an educational assistant within school and is
primarily involved with special education, mainstreaming in physical education and participatory events. It is
anticipated that James will remain in his home community and attend public schools through age 21.
Neuropsychological testing indicates James is not trainable for academic or technical endeavors. James will receive
all education and special education services and therapies to prepare for independent living and vocational skills.
James will receive transitional services for independent living, as he may be capable, and vocational skills through
public school system. There are no additional costs incurred in participation of special education.

- 29 -
Vocational Plan
To this writer’s knowledge a vocational assessment has not been completed with James. While James’s pre-injury
developmental progress and cognitive abilities were age appropriate, following the injury in question James’s test
scores and behavior indicate he has lost significant intelligence quotient points and now falls into range of mild
retardation. Neuropsychological testing indicates James is not trainable for academic or technical endeavors. James
has cognitive skills to be trainable to participate in supported employment despite his dense right hemiplegia. It is not
anticipated that he will competitively employable. Barring significant behavioral changes James will be well suited to
remain in local community and with the support of his family and caregivers he will participate in supported
employment program. The only current local opportunity is to participate with Kona Krafts in supported employment
with the aid of a program vocational counselor and job coach. James is most likely to require a high level of support
services.

Vocational Services 71
Vocational services and support provided by Kona Kraft include a one time service fee of $9,800 for the following
components: Initial pre-employment assessment, job search, on the job training and follow-up retention services. One-
time fee and fee is inclusive of a total of one year retention services. In the event that James should lose his job and
not be readily able to assume another or experienced behavioral difficulties which caused the loss of the job, in order
to once again avail him of the service a second fee of the same amount would be applied. James would require
additional job coaching services which can be purchased at $20 / hr. to extend as long as necessary but estimated at
30 additional working days would be adequate.

Cost $ 9,800 one time fee in 2015 Recommended by

Dennis Physiatirst, MD
Wayne Eklund, RN

Job Coach 72

Cost $ 20 / hr. Recommended by

$ 4,800 in 2015-16 Pediatric Physiatrist, MD
$20 / hr. (8 hr. day) (30 days) = $4,800 Wayne Eklund, RN

Housing / Home Furnishings

Home Purchase 73 & Renovation
Angela K does not own a home nor does she rent a separate dwelling for her family due to an inability to pay full
expenses for such a dwelling. James, his brother, and mother, as well as newly brain injured aunt live with James’s
maternal grandmother in a 2nd story, 2 bedroom condominium unit. There is only one entrance and there are 15 steps
to gain entrance and to exit. The condominium building is built on a steep hillside, there are no lawns, and the parking
area, also on the hillside is inclined black top. James must share a bedroom with his brother and mother. This
dwelling is not amenable to accessibility modifications and it is too crowded to allow the sort of quiet and structured
environment James requires. James will require a wheelchair and scooter, both intermittently in younger years and
later as he ages with additional wear and tear on his joints secondary to dense right side hemiplegia. The
grandmother’s condominium is not amenable to wheelchair use or major accessibility modifications that James
requires.

A survey of available moderate 3-4 bedroom 1 level ranch style homes in the area of Kialua Kona, Hawaii reveals the
range of prices to be between $259,000-$359,000 (259 K + 369 K=618,000/2) with average price to be $309,000. In
reviewing multiple listing descriptions the likely purchase price of an existing home in good repair, not requiring repair
costs for occupation is $350,000 to $375,000.

Prior to the purchase of any home, with James’s needs in mind, a survey for accessibility and modification needs
should be performed. In addition to location with community access the following issues must be addressed:

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 A fully accessible home will facilitate independence in daily activities. Ideally the home should be a one level
ranch style structure, with at least 3 bedrooms, 1 st to accommodate James’s mother and brother, in addition
to James and later to provide a space for a caregiver to stay overnight. Doorways should be wide enough to
permit a wheelchair to pass safely. The home may require ramps for safe entry and exit and James’s
bedroom may require an emergency exit. The bedroom closets or storage should be modified to allow
independent access. Light switches may need to be lowered and electrical outlets may need to be raised.
The home should have a fully accessible bathroom with roll-in shower and an accessible sink and commode
(toilet). James will require a raised toilet and surrounding grab bars. The kitchen should have table height
counters that are accessible with accessible appliances, modified storage and suspension drawers. Flooring
must be able to withstand use of wheelchair on a regular basis. Ideally, parking must be accessible to the
house and covered for protection during inclement weather.

It would be highly unusual to find a home that has been previously constructed or modified to fully accommodate
wheelchair access or have an accessible bathroom. The typical cost of the modification of a bathroom is $16,000-
$18,000 (including labor and materials) and the typical cost or modification of a kitchen is $8,000-$12,000. For the
exploratory purposes of this plan and report I have estimated the total costs, including purchase to be $375,000.

Lift Chair 74
As James ages it will be more difficult for him to rise to standing from a sitting position. It is appropriate for James to
have use of a lift chair which rises to his level to assist in sitting without a free fall and to raise himself to near standing
before exiting chair. It is anticipated that James will require this furniture at approximately age 56. The chair is to be
replaced after 15 years; purchase and cost is inclusive of set up fee.

Cost $ 1,635 in 2050 and then every 15 years Recommended by

Pediatric Physiatrist, MD
Wayne Eklund, RN

Attendant75 / Respite / Residential Care

Care given in the home will require the assistance of a personal care assistant. Respite care is required during periods
that a family member or care attendant is no longer able to care for the individual, or when the residential setting
provides a better environment for care needs to be met. The primary option considering in James’s case is that he
remain in the home and community as is commensurate with his abilities. To assure quality of care an JACHO
accredited, licensed and bonded agency employing certified nursing assistants is utilized to provide attendant care.

Individual & After School Care

Beginning in the spring of 2003 James has had the benefit nurse case manager who coordinates with the family a CNA
care giver who provides support and supervision in after school activities. Services include academic support,
appropriate dietary supervision, pacing and rest periods, socialization and adaptive and appropriate mainstream
activities in which James is supervised and attended by the caregiver to activities such as horseback riding, supervised
adaptive aquatics, martial arts, choir and seasonal sports. The program is set up for 4 week days per week with
direction to extend to 5 days per week. Individual care will extend year round, 50 weeks per year.

Cost $ 19.70 / hr. base cost, 4 hours per day Recommended by

$ 78.80 per day Pediatric Physiatrist, MD
$ 19,700 per year Wayne Eklund, RN

Respite Care
The family is the one constant in the child’s life while the service systems and support personnel within the child’s
health care system fluctuate. The effects of severe traumatic brain injury to child have great effects on the family. .

- 31 -
Significant behavioral challenges can be expected to occur as James ages, family adjustment issues will require
addressing. James also requires assistance from family and parents to regulate behaviors and to be very clear what
his behavioral limits and expectations are, in a way that is productive for him. The additional stressors on the family,
and in this case James’s mother, require a great deal of energy. Respite care is an effective means by which to allow
James’s mother to maintain the level of energy necessary to be his primary care provider through his majority. It is
recommended that James’s mother or primary care provider receive 8 hours of respite per month.

Cost $ 19.70 / hr. base cost Recommended by

$ 156.60 per month Pediatric Physiatrist, MD
$ 1,891.20 per year through 2015 Wayne Eklund, RN

Independent Supported Living

James will live with supported independence in his own dwelling and in the community with attendant care for support
and assistance but primarily for safety. Attendant care is available for those periods when James not participating in
supported employment for assistance with activities of daily living and socialization.

Cost $ 19.70 per hr., base cost 10 hours / day Recommended by

during work week (5 days/ week) Pediatric Physiatrist, MD
10 hr./d (5 d/w)(50 w)= 2,500 hr./yr. Wayne Eklund, RN
16 hr./D weekends and vacation
16 hr. (118 d/yr.)= 1,888 hours/ yr.
$ 86,444, per year - begin 2015 thru 2055.
$19.70/hr. (4,388 hr./ yr.)
$ 114,732 per year beginning 2056 thru LE
Retired, 16 hr./ day year round
Equivalent to 5,824 hr. year

Transportation
Transportation costs include travel to medical providers, as follows (Every opportunity to combine appointments to
eliminate extra travel is included in these combinations.):

Provider and Location Cost Years of Services

Neurosurgeon, Honolulu $374 2008
Neuro-ophthalmologist, Honolulu $374 2003 -2014, then combine w/ PM/R
2015-LE
Interdisciplinary Rehabilitation $1,496 2005 thru 2014
Evaluation, Denver
Orthopedic Surgeon, Honolulu $748 2003, 2004, 2006, 2012
PM/R, PT/OT, Honolulu $474 2015 thru LE

Additional Services
Case Management 76
James will require a guardian, and a conservator is recommended to help him manage his affairs and resources. He
has a normal life expectancy and will outlive his parents. I am recommending a case manager for implementation and
coordination of the life care plan, but more over for focus to be on quality and consistency of care and treatment as well
as appropriate uses of financial resources and the sharing of information across sites and services. The life care plan
can serve as “a road map” that will guide case management and family activities and decisions throughout the care
continuum.

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The case manager’s activities with James, his families and care givers will be variable. A range of typical time is
provided, as James’s needs are known to be greater around transitions and procedures (Ex: surgeries and therapies)
and care givers will be variable though managed by home health care agency. James will require an advocate
throughout IEP process and IEP implementation within the school system. In supported independent living conflicts of
personality and diversions of thoughts, wishes and direction will arise. The nurse case manager will serve schedule
and coordinate appointments, therapies, and to negotiate and hold the quality and consistency of James’s care on
course.

Cost $ 90 / hr., base cost Recommended by

2003-2010 will see a flurry of events around Pediatric Physiatrist, MD

procedures and transitions, along with after Wayne Eklund, RN
school and summer care, a range of 6-10
hours per month of case manager activities
is expected.
$ 6,480-10,080 / year, 2003-2010
2010-2015, ages 17 thru 21 represent a
very large transition period for both
behavioral maturity but transitional focus on
independent living and vocational skills, it is
anticipated that the case manager will have
10 hours / month involvement with James.
$ 10,080 / yr., 2011-2015
2016 thru LE, James will be involved with
supported employment and have access to
that structure, he will have appropriate
attendant care and case management will
once again require a range of 6-10 hours
per month.
$ 6,480-10,080 / year 2016 thru LE

Documents Reviewed

 All accident, medical, educational records.

 All consultation reports, billing statements, depositions, videotapes and still pictures

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