Medicare: HELP! From In-Patient to Permanent Nursing Home Care

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PlayingLife
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Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by PlayingLife » Sat Sep 21, 2019 4:32 pm

My father needs to permanently enter a nursing home as soon as possible due to severe progressive aphasia along with some other side issues such as COPD and general decline of cognitive ability. At this point he lives at home with my mother and as of yesterday seems to no longer be able to walk or speak.

LTC insurance has been activated as of two weeks ago and I find out Monday how soon benefits will be paid. They could kick in within two weeks, or worst case we are subject to a full 90 day waiting period.

Our father needs care immediately yet my mother is the only one living with him who can help. She was just diagnosed with two herniated discs. Yesterday he fell and dislocated his shoulder. A nurse friend saw him today at his home and couldn't believe the hospital did not keep him overnight. He's in severe pain. As of yesterday he can no longer walk or get up and down the stairs of their bi-level home. He is cognitively "out of it today" and again as of yesterday my mother can no longer care for him.

We toured nursing homes all day today and have one we favor that could receive him as early as Wednesday. Due to my parents' financial situation we need to be mindful of costs and really need LTC insurance to kick in before he's admitted.

Tonight we are sending him back to the hospital that sent him home via ambulance, citing severe pain, inability to be cared for by his wife, and total loss of walking ability. He also is now in adult diapers unfortunately.

Here is where I am seeking advice: I understand if the hospital takes him as an inpatient (NOT observational) they may keep him up to 3 days and then may auto-transfer to a nursing home or rehab facility. Is it possible to have him transferred to the nursing home we prefer and what things do we need to consider? I'm vaguely aware medicare could potentially cover 100% of first 20 days and then a portion, up to 100 days, before we're fully responsible for nursing home payments. If so I am hoping we can get near full medicare coverage for at least the first 20 days. By this point we may at least have the ability to start making payments with help from LTC insurance. The facility we're looking at is $11K and the LTC insurance is $7K monthly. Monthly income can cover the difference. We don't want to burn cash out of savings as my father's pension payments stop upon his death and our mother will be limited to whatever assets she has left + her monthly SS check.

**I have screaming kids everywhere in my house right now and my brain is scrambled from all the health events. I'm sorry my email is already over the place, I'm usual more consolidated and punctual

JPM
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by JPM » Sat Sep 21, 2019 5:59 pm

Assuming your dad is admitted to the hospital, medicare rules determine whether he qualifies for regular admission or observation. If he is dehydrated enough to require IV fluids in hospital that may suffice for regular admission status. Has to be some form of treatment that cannot be done at home to be regular admission. If observation is the status, as you indicated the nursing home would not be covered. If admitted on regular admission status, he would qualify for 20-21 days of rehab if he has some rehab potential to justify that. Physical therapy evaluation may determine that.Confer with the discharge planning dept. at your hospital to get a clearer idea as to your dad's status in the hospital and what nursing home options are available to you.

fru-gal
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by fru-gal » Sat Sep 21, 2019 6:27 pm

I am not up to speed on all the aspects of this, but when my Mom was being discharged from the hospital, we were able to pick the nursing home she went to (for temporary care before going home.) I had to pay the nursing home to hold a room for her for 1-2 days as her hospital discharge date was uncertain and the nursing home had a waiting list.

My understanding is that many hospitals have social workers on staff who can help make arrangements/offer advice.

delamer
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by delamer » Sat Sep 21, 2019 6:40 pm

I am sorry about your father’s condition.

As previous replies have mentioned, there are social workers at hospitals and nursing facilities who can help you sort through your options.

This is a little premature, but remember that your mother could a take a reverse mortgage on her home if she needs income after losing your father’s pension.

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cheese_breath
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by cheese_breath » Sat Sep 21, 2019 6:47 pm

fru-gal wrote:
Sat Sep 21, 2019 6:27 pm
I am not up to speed on all the aspects of this, but when my Mom was being discharged from the hospital, we were able to pick the nursing home she went to (for temporary care before going home.) I had to pay the nursing home to hold a room for her for 1-2 days as her hospital discharge date was uncertain and the nursing home had a waiting list.

My understanding is that many hospitals have social workers on staff who can help make arrangements/offer advice.
You can select your preferred nursing home, and the hospital will usually send you there if its willing to accept you. Normally they will if they have an opening. But once in DW's case my preferred home declined because they didn't feel they had adequate staff to accept another patient as sick as she was at that time.
The surest way to know the future is when it becomes the past.

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cheese_breath
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by cheese_breath » Sat Sep 21, 2019 7:00 pm

Once you get him settled in you should meet with an elder law attorney to explore financial options if it looks like he might become a long term patient.

edit: When I see the word 'progressive' it spurs me to suggest you also investigate his suitability for palliative or hospice care.
The surest way to know the future is when it becomes the past.

Kennedy
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by Kennedy » Sat Sep 21, 2019 8:17 pm

I'm very sorry about all the stress you're under right now. Dealing with both young children and sick parents is very challenging.

Be aware that Medicare will only pay for rehab (first 20 days at 100 percent and then days 21-100 with a copay of around $170/day) if your father is making steady progress in improvement. If he is not improving in rehab, the nursing home will work toward discharge or ask that you pay privately (including the LTC insurance money) if you want him to stay.

Further, he must have been admitted to the hospital for three days prior to the nursing home/rehab admission in order to meet Medicare payment requirements.

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cheese_breath
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by cheese_breath » Sat Sep 21, 2019 8:43 pm

Does your Dad have a medigap supplement plan? Some of them will pay the 20% copay for days 21-100 of rehab, assuming the rehab continues to meet Medicare requirement. I'm not as familiar with MA plans, but I'd bet some of them would too.
The surest way to know the future is when it becomes the past.

TheDDC
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by TheDDC » Sat Sep 21, 2019 9:16 pm

cheese_breath wrote:
Sat Sep 21, 2019 8:43 pm
Does your Dad have a medigap supplement plan? Some of them will pay the 20% copay for days 21-100 of rehab, assuming the rehab continues to meet Medicare requirement. I'm not as familiar with MA plans, but I'd bet some of them would too.
This would be a good question to ask.

To the OP: I had just gone through this whole situation with my mom earlier this year, though for my mom it's not cognitive, it is entirely a physical affliction affecting her that necessitated skilled nursing care after hospital discharge(s). She is also getting PT/OT and I can say with 100% certainty (after dealing with two separate SNFs) that you will need to follow up with all parties at the skilled nursing facility on a regular basis as they may try some dirty tricks to claim he is not "progressing" and that they will refuse to submit records for Medicare approval for therapy. Some of this depends on the standards of the facility as well as whether they have an outsourced therapy staff. You will want to make sure if PT/OT is in your dad's future that the facility hires in-house therapy staff. This matters greatly as there are fewer layers of bureaucracy to fight when it comes to obtaining required Medicare approval for therapy services.

Questions to ask (besides whether the SNF employs their own PT/OT staff or outsources): What is their infection rate? How are they keeping metrics on patient progress? You will also want to speak to their medical director or senior nursing/medical staff to get a good handle on procedural concerns. You may also have to prepare yourself to have your dad moved to a different facility if your concerns are unmet. Like I said, my mom went to two of them. She finally settled into the place where we should have sent her in the first place (but just didn't know).

Feel free to PM me with questions as you will no doubt be chasing details in many directions and may have more questions than can be answered in a few lines on this forum. Don't let the SNF boss you around with respect to payment. I would also echo the suggestion to meet with a competant elder law attorney. Believe it or not they ARE NOT entitled to a complete transfer of wealth from your family to them! Also make sure your father (or mother) is able to sign the admissions paperwork. You do not want to be on the hook for any expenses related to the endeavor. SNFs (even the best) are vultures, and get ready for the screwjob on the billing. I'm talking "assessment fees", fees for random stuff you didn't ask about.

Most exclusion periods are 100 days if you have that on your LTC so you may be on the hook until then. However, make sure you NEGOTIATE charges and let them know what number you have to work with. "I'll have to think that over." "Here's the budget, and there's no more. Can't squeeze it from anywhere." are phrases you need to learn when talking to these places. You may need to set up an irrevocable trust to protect assets or make sure your parents are "judgment proof" - a term that many more BHs need to learn.

Good luck!

-TheDDC
Refreshingly, a double barrel shotgun blast of truth...

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cheese_breath
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by cheese_breath » Sat Sep 21, 2019 9:42 pm

TheDDC wrote:
Sat Sep 21, 2019 9:16 pm
... you will need to follow up with all parties at the skilled nursing facility on a regular basis as they may try some dirty tricks to claim he is not "progressing" and that they will refuse to submit records for Medicare approval for therapy...
Another dirty little trick they play by omission... Medicare will pay for therapy when the patient is improving according to plan, but they will also pay for therapy "when the services are necessary to maintain a patient’s current condition or to prevent or slow a patient’s further decline or deterioration."

https://www.medicareadvocacy.org/jimmo- ... case-faqs/

You don't hear much about the second one.
The surest way to know the future is when it becomes the past.

clip651
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by clip651 » Sat Sep 21, 2019 11:35 pm

Talk to the social worker at the hospital. Ask lots of questions. This is the best place to start in terms of understanding procedures at the hospital, and how his insurance works for transfer (is he just medicare, or medicare plus a supplement, what facilities are considered in network, etc) which are some of the questions in your opening post.

Also tour the facilities you are interested in and ask lots of questions.

If for whatever reason you're not able to secure admission to the hospital and/or skilled nursing facility in a timely manner, you may need to consider privately paying for some home health care to bridge the gap temporarily, so that your father is taken care of and your mom is not injured in the process. But start with the social worker at the hospital. If the first social worker isn't helpful, ask if there is another one on staff.

And take a few minutes to take some deep breaths. Hang in there. Sorry for all you are going through.

best wishes,
cj

clip651
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by clip651 » Sat Sep 21, 2019 11:38 pm

I forgot to add -

Along the way, make sure all these recent changes in your father are fully investigated medically. Make sure you understand what is happening / why this is happening to him, and whether there are any treatments that can reverse or slow this sudden progression of his problems. (This isn't medical advice, it's just advice to be his advocate and make sure you become informed enough about his medical care that you are satisfied that he is in fact getting good medical care, both diagnostically and any appropriate treatment.)

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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by fru-gal » Sun Sep 22, 2019 3:11 am

clip651 wrote:
Sat Sep 21, 2019 11:38 pm
I forgot to add -

Along the way, make sure all these recent changes in your father are fully investigated medically. Make sure you understand what is happening / why this is happening to him, and whether there are any treatments that can reverse or slow this sudden progression of his problems. (This isn't medical advice, it's just advice to be his advocate and make sure you become informed enough about his medical care that you are satisfied that he is in fact getting good medical care, both diagnostically and any appropriate treatment.)
Look particularly at whether medication changes are affecting him adversely.

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PlayingLife
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by PlayingLife » Sun Sep 22, 2019 7:45 am

Hi everyone,

I have been off BH's for a long time. All your responses is a great reminder of how great this community is.

I got home around 12:30AM last night after going to the hospital at 7 to pick my sibling up. Here are the quick bullets....

*His was sent home Friday after having a dislocated shoulder. My mom had fought this as his ability to walk due to the fall went from 10% to 0%. He also was wetting himself continuously since the fall and this has not stopped yet. He stopped eating and was drinking little. There was some immediate noted cognitive decline. A nurse who typically sees him weekly watched him yesterday while we toured nursing homes. She validated all of these symptoms and stated she was shocked he was sent home

*We did call an ambulance last night as it's now physically impossible for my mother to care for him and he was showing high levels of pain and the lingering symptoms noted above. Upon arrival at the hospital (same hospital as first night) it was realized his should was dislocated. They tried treating with tylenol and upon him screaming they up'd it to some morphine and fixed the shoulder. This was around 6:30pm shortly before my arrival. Upon arrival my sibling is saying they determined they would be taking him in as an inpatient but there was a change in staff and finally after many questions, at 11:30 PM they deemed him observational but would need to move him to a private room on another floor for several hours of testing prior to discharging him

*My father has Medicare has primary and BCBS as secondary. Unfortunately he and my mother do not know what observational status benefits are covered and so we worked to hopefully try and protect them from massive medical bills by pushing for him to be considered an inpatient. After some confrontation with the DO and the nurse who were giving us all of this information, they finally sent down the Admissions MD. The MD agreed the symptoms were alarming and fully investigated him. At about 12:15AM he told us they were changing his status to inpatient prior to midnight

So this morning we will go back to see him and learn of status. I will take all of your feedback with me, especially the advice about meeting with the social worker to weigh options.

Here is ideal situation....

1) They keep him admitted today, tomorrow, and Tuesday, then transferring him to a NH for rehab which medicare will cover. This buys us time for our LTC insurance to kick in, which I believe will be within a week or two. The way the hospital pushed back last night, I don't see this happening

Second best....

2) Assuming they actually did consider him inpatient last night and we weren't BS'd, I really feel they need to monitor him until tomorrow otherwise it would not be considered a safe discharge. I am hoping we can keep him there at least until tomorrow. If they do try to discharge him today we would likely follow an expedited appeal. Even if we lose this I understand we would be covered for only copays until tomorrow at 12pm (if his secondary does not already cover it). I can't see how this would be heavily debated though.

THat's the story in a nutshell, perhaps it will lead to some other ideas. Thank you very much for your comments.

clip651
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by clip651 » Sun Sep 22, 2019 8:09 am

Thanks for the update. Definitely pursue an appeal to discharge if needed. Good job escalating until you found someone who could help him last night.

Be aware that strong pain killers can cause big changes in mental status, ability to stand, etc, especially in the elderly. Sounds like he needed the pain control. During an ER visit with an elderly relative, one of the nurses told me they sometimes have to keep people in hospital until the side effects from the meds wear off. So if he needs strong pain control, that may help him qualify to stay in hospital longer.

Gleops2
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by Gleops2 » Sun Sep 22, 2019 8:27 am

Are either of your parents honorably discharged veterans?

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PlayingLife
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by PlayingLife » Sun Sep 22, 2019 8:49 am

Gleops2 wrote:
Sun Sep 22, 2019 8:27 am
Are either of your parents honorably discharged veterans?
My father is a vet but is not honorably discharged. He served in the Navy under active war times but not within 12 miles radius. We're working with a financial advisor who is helping us understand if he is entitled to any benefits. I have an application for the NJ Veterans Memorial Home but understand this to be a 6-7 month process. We will look further into this and any potential benefits after we immediately place him in a Nursing Home.

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cheese_breath
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by cheese_breath » Sun Sep 22, 2019 9:12 am

PlayingLife wrote:
Sun Sep 22, 2019 7:45 am
... Even if we lose this I understand we would be covered for only copays until tomorrow at 12pm (if his secondary does not already cover it). ...
I don't understand what you're saying here. Could you elaborate? Medigap only covers copays for Medicare approved services.
The surest way to know the future is when it becomes the past.

stan1
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by stan1 » Sun Sep 22, 2019 9:36 am

Best advice so far:

Work with the hospital and nursing home social workers (and hospice social workers, if he is eligible). This is new to you but the staff at these places see it every day, are experts at it, and they know the resources and methods and people to work with. Our experience was that there folks knew what they were doing and were compassionate in trying situations. The nursing home will know how to work with the LTCI policy.

One step at a time. If possible I'd recommend you or one of your siblings take a week off from work to focus on this with your mom. I've had multiple friends need to do this. It's a trying process.

clip651
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Re: Medicare: HELP! From In-Patient to Permanent Nursing Home Care

Post by clip651 » Sun Sep 22, 2019 11:05 am

Another aspect for you to juggle/consider is the loss of his speech. Again, this isn't medical advice, but advice to follow through with various medical and treatment avenues to see if you can help your dad.

Loss of speech can have different causes - be sure someone has tracked down the cause in your dad's case. You don't have to answer these questions in the thread (don't answer here with specifics, or the discussion may get locked for medical discussion), but for instance, did he have a previous diagnosis, something that has worsened recently, or is this all new? It's possible to have something previously diagnosed and also to have something new happen on top of that, so that should be asked about. Has he been evaluated by neurology, speech therapy, and any other specialties that may be appropriate? Has stroke been ruled out, etc? These evaluations may be hampered by your dad's pain and pain medications, but over time, they should be pursued. Even if they have already been done, re-evaluations may be helpful.

In my personal experience with elderly relatives, those with speech and cognitive difficulties can have much more trouble than usual while and just after being in the hospital. The combination of medications, illness, disorienting environment, stress, lack of sleep, pain, even the body position in bed, etc, can all have an impact on speech (and cognition). So, there is a chance that partial speech recovery may occur, and you should pursue finding out how you and the medical professionals can help him if he can be helped.

On a practical level, if your dad is still trying to communicate, ask speech therapy about alternate ways for him to communicate. They should have resources for someone with aphasia. Yes/no questions can be useful if he can nod, blink, or raise a hand to answer them. If he can write or point with his good arm, communications boards are something you could investigate. Pen and paper obviously works if he can write. Communication boards can be simple hard boards or papers with various items to point to (e.g. pain, food, bathroom, yes/no, etc, etc). There are also more advanced techological solutions to communication (apps or dedicated devices if he is used to using modern touch screens), one company mentioned to a relative by a speech therapist is Lingraphica. I haven't worked with them yet, but may in the future for a relative that needs help communicating. I wish I'd been aware of this type of thing years ago, it could have helped for this relative to start using it sooner. The website repeatedly mentions stroke, but their tools are not just for stroke as far as a I know.
Lingraphica
https://www.aphasia.com/

And, as with the social worker, speech therapists vary. If one isn't able to help, try another. They don't all have identical strengths or skill sets.

Again, this isn't medical advice, just advice on how to advocate for your dad from someone who has learned some of the ropes by advocating for my own loved ones as well as some of the loved ones of my friends, etc.

Sounds like you are doing a great job so far. Agree with the idea to take some time off work so you can focus on what your parents need, and maybe find a chance to catch a little sleep for yourself.

best wishes,
cj

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