My mom is in her mid 90’s. Up until 3 weeks ago she was living on her own in her home. This is no longer an option. She cannot drive or cook for herself. She was admitted to the hospital 3 weeks ago for 4 days. That qualified her for the maximum 100 day coverage that Medicare would provide for a nursing home. After just 3 weeks of therapy the nursing home has decided that she is done with therapy and that she must now private pay. After her own money is gone Medicaid will then kick in. Can her family doctor tell the nursing home that she needs more therapy, thus resulting in holding off the private pay? We just don’t think that 3 weeks therapy is enough, and we’d like to exhaust the maximum Medicare stay of the 100 days rather than the 21 days that the nursing home is saying.
I think you may be confused about what Medicare covers. They will cover 20 days of rehab at 100%. From day 21 to day 100, your mother must pay a co-host of about $160. Is that what she's being asked to pay?
If she has a Medicare supplement, that should kick in and pick up the cost.
While there is the issue of whether or not the person is meeting goals, there's also the issue of what the therapists set as goals. In my experience, the family is not consulted to determine if they concur with the goals, which sometimes aren't realistic. In that case my father was released well before he was ready, literally shoved out the door.
What I've also seen is that rehab facilities sometimes segue into specializations, some of younger patients with joint replacements, and in that case, the pattern shifted to quick in, quick out. Older patients with more complex issues made it more difficult for the facility to meet it's QIQO goals, and weren't treated as well. This prompted me to boycott that facility and find a better one, which I did.
I recall that at one point the facility's advertising boasted of a quick turnaround for rehab patients. Older people with more complex medical issues make that boast difficult to substantiate.
A staffer at one of the facilities in that particular consortium of facilities told me this is what's occurring now - each facility specializes in a different aspect of rehab. One focuses on pulmonary and respirator issues. Another focuses on joint replacements. There's nothing inherently wrong with this other than that "specialty" should be explained to family and patients before the facility is selected.
Some years ago, we experienced the opposite situation; the rehab facility tried to extend my mother's stay past her recovery point, even though her ortho doctor felt she was ready to go home.
What were the specific reasons for your mother's rehab? Was it overall general health, and if so, were the facility's goals ever explained to you?
Based on your description of your mother's status though, it does sound as though it's appropriate to consider a higher level of care. We've been through that; sometimes it's like a minefield as many of the agencies I contacted and vetted just didn't meet standards.
MichiganGirl, I too live in Michigan, and this is where I've seen this specialty trend in rehab. If you want to share the specific name of the facility, PM me. I might have some more info to share, if it's one of the ones we've used.
So Everything was fine and then it’s not...... so did she have a fall? or a stroke? A fall can find them going from pretty good on ADLs to totally bedfast & onto hospice - it happened to my mom. Sometimes sadly there flat is no progress.
For both my mom & MIL, once in a LTC facility, the MD with oversight on all care will be the MD who is the medical director of the LTC. The old internist or family doctor is no longer the primary physician. If there are orders or medications from old MDs, the facility will evaluate and blend in as needed. But old MDs are not determining care plan anymore. PT & or OT will still be done as a part of being in a skilled nursing facility but perhaps just twice a week.
My mom had meds from & continued to see her old retina specialist for the first few months after she moved into NH but it was only due to a well established care plan for the type of surgery she had before moving into the NH. & I took her for the visits. But all her other old docs fell by the wayside once moved into the NH. Care is centralized through the medical director at NH. For us the only other time it changed was when mom got onto hospice as the MD of the hospice group worked in tandem with NH MD.
You mention “Medicaid will kick in”. So is mom already on Medicaid?
If not your mom is going to need to do a Medicaid application. Try asap to get the list of documentation needed from admissions or SW at the NH. There are all sorts of things needed and can seem quite overwhelming.
If mom has a home (it sounds like she was living on her own in her home) I’d suggest to have a family meeting to discuss what to do with her home IF she realistically cannot return to it. Medicaid usually allows for their home as an exempt asset for Medicaid. Although that sounds fabulous.....HOWEVER & 2 big howevers...... 1.Medicaid requires a copay or SOC (share of cost) of all her monthly income to the facility so mom will have no-none-nada of her $ anymore to pay on house realistically. All she will have for $ is her smallish monthly personal needs allowance which most states have at $50 or $60. This factoid seems to be often not clearly described to family. & 2. Medicaid is required to do an attempt to recover all costs paid on care from the estate after death. That house will become an asset of her estate. It’s referred to as MERP. There are all sorts of exemptions and exclusions to MERP but it’s totally on family to deal with whatever paperwork or legal needed to get through the Recovery process.
Also, as others have noted, if either (1) she is not making satisfactory progress or (2) the specific problem of admission has been adequately treated and stabilized, then Medicare will not authorize payment for additional days.
You definitely need to hold a "care conference" at the facility. However, just remember that it's Medicare that is calling the shots on this one!
It sounds like your mother is in need of custodial care, which Medicare will NOT pay for. This must be either private pay or Medicaid.
Speak with the social worker at the facility about your concerns and intentions. If she is going to be put on Medicaid, she will likely be given therapy in a few weeks again to see if she can make any progress.
If your mother leaves to go to another facility or home, either the new facility's doctor or her family doctor can order PT, but insurance won't pay for it if no progress is being reported.
The hospital kept my Dad for three weeks and a few days at no charge to us, with a discharge to home with Home Health for weeks and then a referral to out-patient PT at the Sister Hospital that did In-patient PT.
You may have missed the original appeal right to send Mother to In-patient PT at an advanced hospital like facility.
Worse case scenario, can you move her back home and ask if Medicare will pay for In-home PT/OT/ST? OR could you take her home and have her go to Out-patient PT. I told my Dad’s that the Ortho Doctor wanted them to be agressive and High Goals! Around every six months my Dad’s doctors write new prescription for Out-patient PT to bring Dad back up in stamina and strength. He enjoys it, even with his Alzheimer’! I almost forgot that the Ear Doctor also has written scripts using the necessity of Balance Therapy.
I would suggest that you do yourself a favor and go to Ira Lef Elder Law Attorney website iralef.com to give you some insights, as he is in Georgia, and each State Administer Medicaid Laws differently. One example is that in Georgia And WV if the patient states she intends to return to the home from SNF/NH AND someone lived in the household for two years prior to admission to facility Medicaid was not able to force the sale home upon death as the person whom cared for the patient prior to admission can keep the home. But these laws change year by year.