Discharge from inpatient psych unit to long-term memory care unit, Medicaid pending. Can the family choose the facility?

Hi, I'm a Social Worker at a LTC facility. Here's what I know. It sounds like a hard situation. In an ideal world, the family would be given a list of facilities that have a Medicaid bed available so they can go tour and make a choice, but this is not always realistic and here's why. First, finding a Medicaid bed in LTC is very hard because each facility only has so many medicaid beds available, and well, once a patient has one of those beds, they often stay a long time, so beds rarely come up. In my area, the SNFs that are highly rated don't even take LTC Medicaid patients at all. It seems that the lower rated facilities are the ones with beds available, unfortunately. Second, if a SNF that had a LTC Medicaid bed available, had the choice to take a new patient with Medicaid in place already vs one whose Medicaid was still pending, they may choose the one with the Medicaid in place already. Third, if there is a facility with a rare Medicaid bed available, it will certainly not be available for long since there are so many other patients looking for a Medicaid LTC bed, so there is not a lot of time to make a decision. As long as the current facility social worker has been communicating with family and documenting their many attempts to locate a facility that the family would prefer, but without success, there is no other obligation except to find "a" bed, not a "preferred bed". Once a discharge order has been written by the doctor, I have 3 days to move a patient. I hope this sheds some light on your difficult situation. Best Wishes.

They do not have to remain at this facility for the rest of their life.
Medicaid allows for a lateral transfer if the new place can provide the level of care needed.

Now doing this will be a total ballet to accomplish imo. Timing mucho importante! I moved my mom from No 1 to NH#2 at about month 9 and AFTER she had gone thru the Medicaid Pending phase and been totally Medicaid eligible. #1 had morphed beyond what I could deal with administratively, like 3 administrators, SW left & vacant, chronic billing cockups and the last straw was the medical director - who had been her gerontologist prior - was not going to renew his contract. Anyways I found another NH, that had gerontologist from her old group as medical director there, and they had open beds. I did a evaluation request and hippa release form to new Nh. Admissions from NH #2 sent out a 2 person team to visit mom to see if they could provide the level of care needed. They actually called me from mom’s bedside to tell me she was all good as far a ps they were concerned for lateral transfer. I went next day to new NH to fill out transfer paperwork that #2 would send to the state and then faxed over a notice of move with exact date to the corporate HQ of NH #1. It was about 8 days before EOM.

Now this is the sticky part, the month of the move BOTH NH must be paid the exact copay or SOC (share of cost) due for that month. I did NOT have NH#1 as the rep. Payee for mom’s SS and civil service retirement; she continued to have it direct deposited into her checking account and I paid the NH the exact to the penny as per Medicaid eligibility letter check every month. I as moms dpoa still controlled her monthly income and the $60 a mo that remained behind each mo as her personal needs allowance. If the NH is this lady’s payee, that system will need to be changed and this may not at all be easy...... the old NH - especially if it’s part of a chain - could footdragg to forever to release their payee status and it’s not like the lady can run down to SSA office to do this in person..... Anyways I scheduled the move for like the 6th of the month. So after mom got her paid on the 3rd of the mo SS & usually on 4th of the mo federal retirement $, so both NH got paid by checks to the penny for that months copay divided by the # of days in that exact month. Also ahead of all this, as the writing was on the wall, that this NH wasn’t working out, I got her personal needs trust account down to zero and either took her out to visit her old beauty salon or paid in person the at the NH beauty shoppe directly for mom’s visit.

NH2 let me set up mom’s room the day before, so I got basically everything moved out ahead of time & got photos, clock, new curtains up, closet filled and spoke with her abt to be new roommate. The new NH required that she be there by 10/10:30 and be able to go to lunch there the day of move.

Also - and this is super important- you have got to get all her medications. For NH they usually are done in 90 day blister packs held on hangers or in 90 day jars in a locked closet at the nurses station. New NH really stressed all meds must be taken as Medicaid &/or Medicare will not pay for duplicate medications. And some meds require extra paperwork if they have to be reissued within a 90 day period. So if you don’t get her meds, you will have to private pay for all her prescriptions and this could be quite expensive. I was totally prepped, with pint ziplocks and Sharpie markers. The floor nurse was especially hostile and basically dumped mom’s meds on the countertop. Ziploc to the rescue.

My mom was ambulatory, so she was able to ride in my SUV. Drove to new NH and in plenty of time. They did a new resident announcement at lunch and had her at an activity later that day. The new place has got to, got to, be at the ready to work with you on doing the transfer.

It can be done but as I said it’s a bit of a ballet as it has to synchronize on all sorts of levels.

Has the family picked a better option and does that place have Medicaid beds open? That’s the million dollar question.
Also can they tour the facility that has the open bed after studying the Medicare write ups? It’s very hard to judge facilities solely based on the Medicare ratings without seeing them. A 5 vs a 1 would be red flags, but a 4 vs a 3 isn’t so clear, or maybe not a really big deal. If the desired facility has an open bed, there should be no problem requesting that facility. If not, you need to find out how long the psych unit is willing to wait.

When mom was being released from her rehab Medicaid Pending to long term care, the rehab social worker was very accommodating. They had open beds at their attached LTC building, but I didn’t want her to go there, as it was a long distance from me and I was driving it daily. So I applied to my #1 choice closer to my house. (A 4 Medicare rating) Rehab said they wouldn’t kick her out while I waited for a bed to open. And I waited. And waited. Finallly after another month I just couldn’t take the drive anymore, the #1 choice still didn’t have a bed, so I took our #2 choice (a 3 Medicare rating) But it was close to my house and since I was going almost daily I figured I could oversee or compensate for the lower rating. It worked out fine. My point is having an available Medicaid bed is vital to their choices. It is possible to transfer between facilities later, but I haven’t seen it done very often in my experience. The devil you know is better than the devil you don’t, so to speak.

So it isn't just the choice of facility, it's also the daunting state transfer issue.

Well, perhaps the family had better start with the end point: see if they can find a facility that would hypothetically would be ideal, and then beg support from the facility's admissions team + their own state's Medicaid system. These are the people who will know how you find the way, if there is a way.

The big point they have on their side is that it would undoubtedly benefit the patient to be near his family - the transfer would be in his best interests, and all those who have any responsibility for his welfare are obliged to take that into account.

But other than that... Gulp. Good luck.

The family should discuss this with the social worker. If they're not happy with the choice of facility this is something that needs to be discussed.

I spoke w/ the family and it seems as if none of the long term facilities want to place the patient due to Medicaid! They were told by the psych social worker (today) that nursing homes would rather have private pays so they turn down the Medicaid patients. Is this something that you think is true or do you think it's because of the "psych" diagnosis?
The family would rather have the patient relocated to the state that they are in instead of being so far away. What other options are available? Money is very limited. The family did do their best by having the Medicaid approved but now it looks as if it's not enough. Obviously, Medicaid is not approved for the state that the family is in so that's a complication.
We'd appreciate any input/information that you may have to help, thank you!

Onlychild, if you’re strictly a close friend with no DPOA, no MPOA, no signatory on her banking, no HIPPA release, etc already existing between you and your 82 yr old friend, there’s not much you can do unless you want to totally private pay for her care and take on full financial responsibility for her. And unless you’re Uber wealthy that makes no sense to ever do. Yeah it’s a harsh reality.

it sadly doesn’t sound like she could go back to living in the community or living independently. She needs a psych ward, locked care type of living situation, right?

Her family states away either need to step up and be in your city to deal with their family member (mom?\aunt?) and either do whatever needed to get her thru Medicaid eligibility and placed into a facility that meets her needs. Whether that takes going back & forth for weeks or more. If no DPOA already done, and if she’s not really competent and cognitive that means trying to get guardianship. And they need an atty in your state for this. Guardianship like Medicaid is state specific. If no family member actually is a resident of the state, it may be that what is considered best is for her to become a ward of the state of where she lives now with a court appointed guardian named that oversees her finances and eligibility for whatever programs available. Often the court appointed guardian can get things expedited way way beyond what regular folks can ever do.

If her family doesnt start to do something tangible, the facility where she is now will likely do the following:
- 30 day notice sent to family and anyone else who may have signed off on her paperwork. 30 days to either to move to more appropriate facility for her level of care or someone signs a legally binding financially responsibility contract. Private pay psych facility will be very $$$$.
- CC of the 30 day to APS, so that APS is on notice that they could be asked to intervene in 31 days
- CC to whatever probono legal clinic in your state. This doesn’t mean the legal clinic sent has to deal with it, its more imo of a CYA for the facility that someone legal has been notified. Most probono clinics do NOT deal with these type of issues. Where I live there’s 2 law schools and both probono mainly deal with juvenile justice issues.

If nothing done, then after day 30, APS is asked to seek an emergency ward of the state status for the resident. Judge grants a temporary guardian and usually the guardian comes from an already vetted list that the court has. Guardian can then move her to another facility if need be. But they are in charge. After like 90 days there will be a hearing on the temporary status, and at that hearing family or whomever can petition to become guardian.

Unless her family can either care for her in their home in another state or private pay for her in the new state till she is able to establish residency, there may be no real options but to let her move into the only facility that will accept her (whatever their “ratings” are).

Just went through something like this.
1. Live 1000 miles from younger brother who needs LTC. Unable to travel to him due to my own health.

2. From hospital I was given news that he could not live alone anymore due to "Self Neglect". I was told by SW that she would look for a facility for my brother, she gave me several but I will say that there are not many beds available and finding a Medicaid bed is really hard. Most places want ..... not too sick, quiet old ladies, who are Self Pay!!

3. I contacted my brother's personal doctor.

4. Doctor gave me names of LTC facilities in which HE has affiliations.

5. Communicated list of LTC to SW and she made sure they also accepted MEDICAID.

6. Brother has some money from small IRA which he must spend down to get Medicaid. He will do this quickly as he doesn't have a lot of money.

7. He was sent to a facility for rehab, and will transition to LT in same facility. He is Self Pay and got in immediately...., but the facility must also offer a Medicaid bed for the future, as he will run out of money soon. I do not want him moved again when his money runs out. ( NH LOVE self pay.) In NJ over 65% of all folks in LTC are on Medicaid or heading toward it as their funds run out.

8. In NJ be prepared to pay over $10,000 a month until the patient has "spent down" to $2,000.00 in assets. Patient's are allowed $50 a month while on Medicaid for personal items...everything is taken, SS & whatever else while on Medicaid.

9. He has a small home which also needs to be sold, old car.... must sell everything to get down to the $2,000.00 threshold before Medicaid steps in. Spend on anything else except the patient and the patient will be penalized by Medicare by the amount miss-spent.

So, yes, you should get a choice. BUT you may only have one choice. I did find out that the care is the same whether you are a Medicaid patient or Self Pay. CARE DEPENDS ON THE DOCTOR!! So, my suggestion is to find a place where you or someone else knows the attending doctor for the NH.

This is a very stressful part of life for family or persons who help someone else in need of special care. My prayers are with you. I know how difficult this can be and it doesn't always turn out the way we think it should.

Yes, the family can insist that several options be given to be check out. However, facilities really need to be seen, not just looking at their ratings.
Don't let the SW bully you into anything. The SW's job is to get them out asap. I, unfortunately, encountered this myself...
Medicaid beds aren't that great to begin with. I found that Senior Group Homes offer a small environment with better care than ANY facility out there, even the expensive ones.
However, that was chosen because he was wheelchair-bound and had no interest in or outside events. He's content to watch his old movies and have visitors from time-to-time. He's very private.

All the best to your friend!!

If the hospital is ready to discharge you should be involved in the discharge process. However, finding a Medicaid approved bed is sometimes difficult and they may be limited in there choices. I would recommend the following:
1. Asked the social worker for a list of facilities with Medicaid approved beds.
2. Tell her that you will go and tour these facilities immediately and let her know which home you would like your loved one transferred too.

Potential Problem
It is much more difficult to find a home that will accept a resident when they are "Medicaid Pending." Homes are not sure if the Medicaid will or will not be approved and some homes do not want to risk that the resident will not be approved and they will be left with a huge bill.

Good News
Once the resident is Medicaid approved you can move them to any Medicaid approved home you choose. It is not difficult to move a Medicaid resident from one home to another.