My mom is 90 and fell and broker her arm and has been in a Skilled Nursing Facility for about 35 days. Before she fell she was driving fine and is very extremely cognitively "with it" and has lived alone pretty much doing fine although she tires very easily. For the past week to 10 days in the nursing home she has been walking independently with no walker or cane. When the PT and OT evaluate her she is able to do everything with absolutely no assistance. She can go to the bathroom by herself, make a meal in the microwave by herself, dress and undress by herself, do a full set of stairs up and down by herself (holding onto the hand rail). She is slow and careful, but she's been through two evaluations and each time they say she is just a little tentative and therefore they won't clear her to go home.
The problem lies in that at day 31 of her stay, her secondary insurance stopped paying and now she is paying $167 per day co pay. She has a very low income and can't afford this and wants to go home. She has had fantastic PT and OT seven days a week and is actually in better shape than before she fell... but they won't clear her, so she has decided that she is leaving Against Medical Advice to go home. Her primary doctor who knows her quite well has already agreed to coordinate home PT and OT and other social services she might need... she does get tired very easily due to congestive heart failure so she receives Meals on Wheels etc.
My question is... should I be worried about her leaving Against Medical Advice? Someone at the nursing facility mentioned calling Adult Protective Services if she leaves and while my main concern is for my mom, I am also worried if I'll be responsible if she goes home and something does happen... if she falls. Also, I heard that her secondary insurance might not pay if she leaves AMA.
Unfortunately, I live a couple of hours away. I told her tonight that I think she should stay until they clear her, but it seems that she has to be absolutely perfect in the evaluations for her to be cleared. I understand that they don't want to be sued, but it seems ridiculous. She is is in so much better shape than any other patient in that facility by miles. Everyone there is walking with a walker or they are in a wheel chair or bed except my mom. She doesn't even look like she belongs there. Even the PT and OT techs are whispering to her that she should be discharged and they don't understand why they won't clear her.
Is this Medicare fraud... trying to keep her there so they can bill for her stay? Why else would they not clear her?
Any advice is appreciated.
I would seek a second opinion from her own doctor, not the doctor at rehab. I am assuming they are different and employed by different employers? If that doesn't work call Medicare to discuss the issue. There is probably a policy in place to address these sorts of issues.
Go to the finance office and tell them Mom has no money for the extra days. That they need to discharge her or agree not to be paid. Bet she is discharged. Mom can do therapy at home, I think. Check that out with insurance provider. If they do nothing, call her primary. If get nowhere with that, call your state Ombudsman.
I love Joann's suggestion to tell the facility you have NO money to pay for further services. I'll betcha too that they release your mom pronto.
Best of luck!!!
Thankfully across the hall from my office was a sport's doctor so he helped me straighten out my arm. Due to the break I had the physical ability of a 3 year old child since it was my primary arm that broke. My handwriting was that of a 3 year old, so was my eating trying to manage a fork with my left hand, what a mess.
Getting dress was a major challenge, especially putting on a bra, and tying shoes. Had to type one handed, oh well, that's the norm with some people.
Thank goodness for on-line grocery shopping, otherwise all meals would be based on what was on the middle shelf at the grocery store !!
It took me 3 months of going 3 times a week for therapy. Thus, recouping from such an injury can take a lot of time. Plus one's mind is in a tizzy afraid falling will happen again.
For your Mom, the facility said that she is a little tentative, thus that tells me she isn't quite ready to go home. Do check with the social worker at the nursing facility to see what can be done regarding paying for the extra days.
My 87 year old Mom did NOT have to pay for anything when she was in Skilled Rehab because her BCBS Medicare Supplemental Insurance covered what was not paid by Medicare.
You and your Mom need to contact the Secondary Insurance Company and find out WHY they quit paying for her care and why she is having to pay a Co-Pay? What part of her care did the insurance company quit paying for? Sometimes nursing homes make mistakes on the forms that they have to send to Medicare and to the Medicare Supplemental Insurances which can result in nonpayment or a lower payment from Medicare or the insurance company.
Also, have a meeting with the people who make the decision as to whether your Mom can go home or not. Ask for the specific reason(s) why your Mom cannot go home. What do they mean when they say that “she has to be absolutely perfect in the evaluations for her to be cleared”? Is it something as simple as the need for a permanent grab bar in the tub or shower? Does she need rails on the toilet? Do the dishes in the kitchen cupboard need to be rearranged so that she can reach them easier? Is the microwave TOO high for her to use safely? Does she need better handrails on the steps into her house or inside her house? Do the people who make the decision think that there are TOO many steps into your Mom’s house and are afraid that she might fall trying to walk up or down the outside steps? Are there area rugs that need to be removed so that your Mom does not trip over them? Does your Mom have an “Alert button” in her house that she can push in case she falls again or does not feel well? Find out what is keeping “THEM” from releasing your Mom to LIVE BY HERSELF again.
WHO at the nursing facility mentioned calling Adult Protective Services if your Mom leaves AMA? Did they give a reason why they might call APS other than “your Mom left the nursing home and you took her to her home AMA”? What are their concerns?
You need to ask more questions and find out exactly WHY "THEY" will not let your Mom go home. It might be because she is 90 years old and you live 2 hours away. You won't know unless you ask them. Good Luck.
They will reassess her and order in home PT and OT, Medicare pays for these services. If she leaves AMA they will most likely resist paying.
I was told that my dad needed 3 to 4 more weeks of SNF but the next day his insurance said they would not pay anymore and overnight he progressed enough to go home. Amazing!
Please make sure she really is ready and able to go home. Try to get the insurance company to do an exception pay if she's not ready. Cheaper for them in the long haul. Then everyone can be assured that she will continue to do well.
But don’t let her sign out AMA for reasons stated in previous posts.
There is a reason they aren’t discharging her and I don’t think it’s fraud. There are probably other folks needing rehab in the wings.
IMO you should visit ASAP & assess for yourself.
Is her home set up to assure she can manage to care for herself? Does she have a Lifeline device to press if she falls again? Her level of care may have changed and her home may need modifications.
I was told my Mom, even with a walker, would need assistance at all times when she returned to the AL. I questioned it because she was only in the hospital, for a UTI, from Tues to Friday. Before that she was walking all over the AL with a walker. When she returned to the AL within 24 hrs she was again walking all over the place.
I really don't see how they can get better when they do PT, OT for maybe a couple of hours a day and then sit them in a wheelchair the rest of the time.
A care conference is essential.
This is what is the real problem. The facilities taking over our loved ones, them deciding what is best and making the decisions. Many times it is money motivated. They will usually decline once the PT is over. I know of someone 91 and living home alone. They try to make a big deal out of normal older aging things. They try to diagnose them with dementia, when it is just normal forgetfulness of old aging.
They love to threaten families. Im sure you would not want her to go home if you felt she was not safe. Help her keep her independence as long as possible. As far as being low income, call your local Office on Aging. They can get you connected with State Assistance Programs that can have meals deliever, aids out to help, and many other servcies.
If you get the doctor and Office on Aging to assist, their threats will mean nothing.
Do what is best for your mom always!
Prayers to you and your mom
It would be better if you or a healthcare provider would call the state and demand that they give her back her care services. She needs it. This is the real issue. No one should be left to live alone with 167 bucks a day or 4000 a month to care for themselves. If that is not feasible then find her an ALF to go to so she can live in it. it includes everything that she will need and still give her some independence.
If making it very clear that the only payment they will be getting is what they get from her insurance (she sounds well insured so they aren't suffering) because she and the family don't have money to supplement with doesn't work I would consult with her primary and or specialist and even the hospital or doctor that signed the orders sending her there about what they can or can't do in this case. It may differ from state to state so these are the people who will either know or know where to send you to get the truth about options as well as raising suspicion about this facilities practices. If they want to keep her or feel it's that necessary they will find a way to get the expense approved or keep her anyway beaus they truly have a responsibility to do so. Funny our problem was as much as the facility agreed mom need the intensive speech therapy and we needed the help, they couldn't find ways to get it approved by Medicare so she was being sent home before she was really ready. They would have approved and sent her to a NH but we knew that was going to hurt more than help her at that point (much like your mom her mobility was great, far advanced in comparison to other in a NH) so we chose to take her home with us, she wasn't able to be on her own yet.
My mom 84 lived alone, also. Wants to manage her own meds (adds to fall risk?) my feelings are if she wants to go home she should. I can get an electronic med dispenser which she will refuse to use.
Take Care
At the conclusion of a very recent ER visit, they did they usual - can she walk with walker, etc... Mom has dementia, has been using a walker for almost a year, has been in MC for almost 2 years. She was there to figure out why she is having extreme leg pain, enough that she has difficulty dressing, showering, walking and sometimes refuses meals because she is in so much pain. That said, she was NOT able to stand for them, not even long enough for me to pull up her panties and pants. She could/would not walk with the walker even with two staff members by her side, yet they discharged her. Test results revealed nothing. Granted she is in a facility, but still, her condition was really poor at that point (we were not looking to get her into rehab or SNF, just trying to determine the cause of this pain), yet they let her go back to the MC facility. Looking back, she was probably upper 80's when she tore her rotator cuff. She had surgery and was released home to her own place the same day (lived alone then, no dementia) and PT was brought in to help her recuperate. How bad was mom's break that she even needed to be placed there? Why not treat the arm and release to home, with services brought in? If she was able, within a month, to do all you say, I would question even why she was there to begin with!
So, given that your mom can ambulate, care for herself, etc, I would have serious concerns about what their reasons are for refusing to sign her out. Yes, she should have some kind of support system at home, at least for a while, to ensure she is doing well and can manage on her own again. One option, can you have her released to move in with you, temporarily, so that she has more support and you can monitor everything for a while before moving her back home?
As others have suggested, I would demand information and reasons for keeping her. If all they can say is she is tentative about doing something, that really isn't a reason to keep someone in rehab in my opinion. Telling them she cannot pay for the stay might help push this along (they CANNOT force YOU to pay.) It cannot hurt to ask Medicare or any supplemental insurance why payments are denied (I thought Medicare covered 120 days???) PCP might be able to intervene as well. Worst case, threaten with legal intervention! From your description, it sounds like she is being held against her will and they just want the money (although there are often waiting lists for rehab, perhaps they have no one waiting and want to keep their beds full!!) Would her doctor be willing to come to the facility and "test" mom himself? If he can see how well she is doing he may be able to override (one would think PCP and family have more authority than some random facility - and again, why did she need to be in this place to begin with?)
Very informative and helpful. It is good to know terminology and what is available because I have found you have to ask for things but unless you know about them you can't ask. The don't tell unless they ask has gone to far with our vulnerable citizens.
Thank you.
If you are afraid Medicare will not pay for her nursing home bill if she leaves AMA, I have previously researched this with Centers for Medicare and Medicaid Services (CMS) and that is not true. It is another falsehood nursing homes tell families and residents.
Your mom may fall at home. She may fall in the nursing home. But, she will likely get stronger at home with therapy where she has to do more for herself---but more importantly she will be happier at home.
It is the role of the discharge nurse to arrange for home care.
Follow the previous good advice.
I would like to add that you may have a doctor in charge sitting on the fence.
On one hand, he/she is saying your Mom can receive the needed care at home.
On the other hand, he is listening to staff say different.
On his third hand, if there is a real medical necessity for her to stay, doctor should be writing for an extended stay appealing the insurance decision, seeking medical approval for a longer stay (longer than Medicare has allowed for what is usual, customary, and reasonable for Mom's condition UCR).
This means, there is not enough information yet. When no one is running the show, exploitation runs rampant. Especially during the holidays, neglect to follow through.
https://www.medicare.gov/coverage/skilled-nursing-facility-snf-care
I did this because several years ago the hospital was going to put my husband in a skilled nursing facility to teach him to walk. To make a long story short, he had been walking fine when they admitted him for a heart problem. They had kept this 83 year man in one position for a week. No turning, no moving around. The last day they had a Physical Therapist get him up and he had a hard time walking. I told them it wasn't going to happen. All he needed was to get up. They were getting the AMA paperwork ready when (Wow) the regular release papers showed up. In an hour he was walking just fine. All he needed was to move around a little bit. Of course I am leaving out my "talks" with the Doctor and a lot of other garbage.