Another Aging-Parent Problem

Parent Cafe
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<p>My father was in the hospital last week, and was discharged to home late Friday over my strenuous objections. I literally begged them to send him to a Subacute Nursing Facility. The last thing I said to the case manager was, “See you tomorrow” and on Saturday morning, sure enough, we went back to ER and after a lovely 10-hour day there, he was re-admitted.</p>

<p>This has happened to him 3 times in the last 2 years. </p>

<p>His post-discharge crises always happen within a few hours, and are exactly the sort of thing that could be handled at an SNF. (This time, it was uncontrolled back pain; another time, he wasn’t completely recovered from Rotavirus and was very weak and still having some continence problems.) These are things that 99.9% of people can get through at home with support, but he has no “reserves” (not sure what to call it) of strength or recuperative powers or overall good health to fall back on. On his best days, he’s near the red zone and a hospital stay knocks him off the tracks altogether and it takes him extra time and support to get back on. He needs to be completely, 100% well before he can go home.</p>

<p>He is fragile physically and mentally. He can do no aftercare for himself at all, and cannot follow discharge instructions. The Assisted Living staff can do a lot, but they can’t write an Rx for back pain, or hook him up with an IV drip for diarrhea-related dehydration. </p>

<p>The problem, I’m discovering, is that there is a hole in the insurance net. I’ve never disagreed in these cases that he’s well enough to be discharged. But Medicare guidelines about SNFs are very strict. I understand that (and as a taxpayer, appreciate it) – but that doesn’t help my dad. Home health care doesn’t kick in until a day or two later, by which time he’s back in the hospital. There seems to be nothing at all for someone who isn’t sick enough to be in an SNF, but isn’t well enough to be home. So he falls through the cracks. </p>

<p>Of course, it’s very stressful and upsetting when you’re 85 years old to have to go through what he went through on Saturday for the second time in a week, not to mention expensive for the insurer, and a waste of hospital resources. What infuriates me is that our 10 hours in the ER were completely predictable and avoidable. </p>

<p>It’s been suggested to me several times this weekend that maybe it’s time to consider moving him permanently into a nursing home. But he doesn’t (yet) need that level of care every day; it’s only post-hospitalization.</p>

<p>When I pointed out to the case manager on Friday night that this is a continuing pattern, she said just said over and over that he didn’t meet Medicare criteria. The new case manager for this second hospital stay said that the past doesn’t matter. I’m sure all of that is true. It still leaves the question: How can we get him the care that he needs for that transitional post-hospital period?</p>

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<p>It sounds like you need to hire a home health care agency. I am not sure what you need to do to qualify, but it’s certainly less than going to a snf. </p>

<p>It would probably be worth it to hire them even if he had to pay out of pocket for a few days to get back on his feet.</p>

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<p>As in, a round-the-clock nurse? Would they be able to handle things like uncontrolled back pain?</p>

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<p>They will follow doctors orders, so whatever your dad’s dr prescribes, they will administer. They could also be used as an intermediary on your dad’s behalf.</p>

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<p>Agree with HHA. The hospital should also have a palliative care department that can help you to coordinate.</p>

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<p>I don’t remember off the top of my head, but I think one of the criteria for subacute admission is how long he is hospitalized. I think he has to have been hospitalized for 3 consecutive days. So if he was admitted and readmitted and has been in for 3 consecutive days, he may meet criteria <a href=“http://www.medicare.gov/Publications/Pubs/pdf/10153.pdf[/url]”>http://www.medicare.gov/Publications/Pubs/pdf/10153.pdf&lt;/a&gt;&lt;/p&gt;

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<p>My heart goes out to you and your family. Right before my son went off the college both grandma and grandpa needed round the clock nurses (a home health care agency–the nightingales). Two of them! Needless to say, they moved from their condo to an assisted living facility that I sorted out for them after they were better. They had been able to live on their own, go to the gym in a golf cart, and even cook. After that, all bets were off. It cost them a fortune, the initial care. There was no special deal. THey got better and helped each other. When my dad died within a two week span ( he went into a palliative care facility for that time which was wonderful and covered by medicare), my mom didn’t do so well on her own in an assisted living place and I had my college age son fly with her across the world so she could stay with me. We do what we have to and usually we don’t have much time to make decisions. It seems ages ago to me. I still pay for their things in a storage shed and that I will deal with in the next year.</p>

<p>All my best.</p>

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<p>Megan McArdle recently had a couple of pieces on The Atlantic website about this issue, prompted by her mother’s recent hospitalization and what she and her husband had to do once her mother was discharged: </p>

<p>[What</a> Cutting Health Care Costs Looks Like](<a href=“What Cutting Health Care Costs Looks Like - The Atlantic”>What Cutting Health Care Costs Looks Like - The Atlantic)</p>

<p>[Explaining</a> the U.S. Home Health Care System](<a href=“Explaining the U.S. Home Health Care System - The Atlantic”>Explaining the U.S. Home Health Care System - The Atlantic)</p>

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<p>Has anyone bookmarked other threads about providing financial support for your aging parents? I’d like to read what has already been posted on this subject.</p>

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<p>This is such a difficult issue. In my state, there are great geriatric doctors and counselors. My parents were in Florida, though, when my mom got sick … and we found the doctors in their area sadly lacking when it came to helping us with these issues. When my mom had to go into hospice, we used a facility rather than having her home … my dad couldn’t handle her needs by himself, and the social worker at the hospital was not at all helpful in getting him set up with nursing care assistance. I was thoroughly disgusted with the lack of help in an area full of old folks. </p>

<p>I am not sure how to advise you, since I didn’t do such a bang-up job figuring things out myself. I just want to send you hugs and tell you that you are not alone.</p>

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<p>Have you tried a different hospital? Maybe it’s worth a try next time to see if they handle the hospital to SNF transition more in line with what you think they should be doing. It’s also worth discussing all of this with the attending doctors before the discharge from the hospital since if they recommend going to the SNF it’s more likely to happen.</p>

<p>The extra week or so in the SNF can make a big difference in recuperation and being ready to go home, as you know.</p>

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<p>You have him in assisted living? Aren’t there staff, who for a fee can provide some of the care during the transition period? Work with him on walking to improve his strength. Clean up after the incontinence, and encourage him to drink? </p>

<p>In terms of a different hospital, medicare guidelines are fairly strict. You don’t need the IV, so are not going to stay for the three days to qualify. What does the primary physician have to say about this? </p>

<p>So sorry, it sounds as if things have been quite difficult.</p>

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<p>Can you throw money at this problem? It seems to me that a few days of private nursing would make a huge difference at relatively little expense.</p>

<p>You seem to expect insurance to cover everything, and perhaps it should, but it generally doesn’t. It seems to me you have to decide whether to spend money on this.</p>

<p>When my mother was 85, on full-time oxygen, living in an assisted living community, she said “It’s a full-time job just staying alive. Life is trying to kill me.”</p>

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<p>Can your dad stay with either you or a sibling until he is is ready to go back to the assisted living facility? When elderly people reach this age and have diminished health they seem to regress when in the hospital. They do very well when surrounded by family who can be attentive to them. The sterile cold environment of a hospital is so disorienting and scarry for elderly patients. They don’t hear the instructions or they are too complicated for them to understand when they are nervous. You can hire someone to come into the house when you are working to make sure he is eating during the day or to assist with basic needs and to provide him with his medicine. </p>

<p>So much of the healing process is about frame of mind and it could very well be that your dad just needs a few days with family every now and then.</p>

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<p>Thanks for all the suggestions, and for the support. Yes, AL staff can do a lot, but they can’t, for example, adjust his pain medication which was the crisis this time. </p>

<p>It does look like private-pay in-home nursing will probably be the best bet for getting him through that first crucial 24 hours back home. Money’s not an issue; I just didn’t know this option existed. So next time he has to go directly home, we’ll have a nurse waiting for him.</p>

<p>The re-admit turned out well for Dad. During our ER stay on Saturday, a nursing supervisor gave me the direct line for the hospital’s Director of Case Management, so I called her on Monday. She was very nice and agreed that Dad now has a pattern which should be paid attention to. She reiterated that they couldn’t order a SNF without medical reason, and gave me several resources for in-home nursing care. </p>

<p>But she also apparently talked to the doctor and the case manager, because they kept Dad for 3 additional days, long after he would normally have been discharged, until he was completely well. My guess is that although re-admits look really bad, RE-re-admits look even worse. I felt bad, because it obviously was a waste of hospital resources. SNF would have been perfect for his needs, but it seems their hands are tied by insurance guidelines.</p>

<p>I learned some valuable things this go-round, one of them from a home healthcare worker. As a Medicare patient, he has the right to appeal a discharge, and the hospital must keep him while the appeal is reviewed. Three consecutive nights in the hospital is indeed one of the Medicare guidelines for discharge to a SNF. So this case, if we’d appealed his Friday night discharge, we probably would have lost, but in the meantime he would have had that 3rd night.</p>

<p>The other is that in the future, I need to be in contact with the case manager from Day One, making sure they know his history.</p>