Oh, man. I need some advice from you experienced folks.
My mother had a stroke in January. She was in acute rehab for three weeks, and then they sent her back to her continuing care retirement community for sub-acute rehab.
She’s making progress, albeit slowly, but when she is not having her rehab (6 days a week, 1 1/2 hours a day) she’s bored. The food isn’t good, she has no one to talk to except when her children call or visit, and she is anxious to go back to her apartment and her life at the retirement community.
We want to spring her, to put her back in her apartment with outpatient rehab and a 24/7 aide. Her doctor agrees that it’s time for her to go home. But the rehab center is making difficulties. They said if we take her out, it would be Against Medical Advice (even though her doctor agrees with us). They threatened that Medicare wouldn’t pay, either for her ongoing care or her care the last few weeks.
We’re not sure how to deal with this. I’m going fly in for a visit Wednesday, to try to get Mom’s apartment ready for her to return to it, and several siblings live nearby, but we are not sure how to get the rehab folks to stop trying to keep Mom in the rehab when she’s not happy there. Mom is 91 years old, and our idea is quality of life NOW, rather than trying to squeeze every little rehab improvement at the expense of keeping her in a hospital-like place.
CF – We had very good experience with the California Medicare Quality Improvement Organization, though I see that Medicare has awarded that contract to a different company than the one we used. They were fast and helpful – in our case, we needed to stop a hospital discharge. In your case, it would be to generate a SNF/rehab discharge without penalties. https://www.hsag.com/es/patients-families/quality-improvement-organization-qio-program-changes/
The part about Medicare not paying for the care she has already received there is what sounds fishy. The rest sounds somewhat plausible. Usually care can be provided at home if the patient is deemed homebound - can’t get out, has no support to drive her to treatment. With MIL, Medicare only paid for PT/OT at home if she and FIL claimed that she was unable to leave the house for any reason. If he took her out to lunch, they would be disqualified. So it is possible that your mom would have to pay for continuing PT if she leaves rehab and is not considered homebound. Definitely time for a family/care team conference, though.
CF, have any of you been around her enough to know how well she is doing cognitively since her stroke? Like spend a full day or 2 with her to see how she interacts and remembers her day? I ask because FIL (stroke in late October) still demands every day to have someone bring him his wallet and car keys so he can go home. In reality, he is nearly helpless. In his mind, he is 70 years old again and able to function independently. Sending him home would be AMA, but he can’t see why. “Home” to him means independent. Someone who knows what her baseline was needs to evaluate whether your mom is able to go home.
@CF, hugs. I don’t know, every state is different, but keep asking who else is there to talk to. We finally got a social worker involved when we moved Mom (3 years ago) from acute care to AL place, but that was OR rules.
@Momof JandL , I too, think staff sees a different person that is there when I show up. Mom is always MUCH better when around family that she is SURE she knows.
And speaking of tough deals? My friend Nancy’s niece is here (CA) from Minnesota doing some tests to get her durable power of attorney and the trust -trustee transfer done. … Sooooo, anyone hear of a threatened shooting in a high school in Minnesota today? Her 2 girls are there in HS and had lock down/swat team involved. … and she is here dealing with her crazy aunt. gahhhhhhh
I bought her lunch, what else could I do?
@cardinalfang we had some issues with acute rehab a couple years ago, and requested copies of all paperwork, they sent to insurance company/ medicare. Helps you know what the pt and OTs were reporting. @MomofJandL - this is also, some good advice. Sadly, I just read about dementia symptoms appearing after strokes. Sorry to relay this, but momofjandl is offering some good advice, just that you be prepare a safe place for your mother.
When my mom returned to her condo , to live independently, an OT had to inspect the home and she made some very helpful suggestions for my mother’s safety.
DH has been great about visiting his dad even though he knows he is likely to get yelled at. One thing that helps on the visits is to see that the staff is friendly with FIL - they seem to know his quirks and are able to laugh with him, because he doesn’t take his frustrations out on them, and even if he did they don’t have to be hurt by anything he says. They are angels on earth for what they do for FIL, and the peace of mind they give DH.
I’m confident in my siblings’ assessment of Mom’s cognitive state. One of my sisters lives in the same town and visits almost every day. My other sister and one of my brothers are also local and visit frequently. Mom has moderate dementia, but she is still very aware of what’s going on. The dementia is one reason we want her out: she’s a 91-year-old woman who is slowly declining mentally. We think she deserves to be at home while she can enjoy it, in her own place, where she can go down to the common area during the day and visit with her friends, rather than a shared hospital room.
Today my sister met with Mom and a representative of the home care company we’re hiring to supply Mom with the live-in caregiver. He too felt that she would be safe with the unskilled caregiver.
@“Cardinal Fang” , do you have POA to request the PT and team meeting reports? Have they been in touch with her MD? The way that the rehab. facility is talking to you is very suspicious. I found the following contact information for you to speak with someone about medicare coverage, it might be worth a call to ask about the information given to you by the rehab facility. Visit go.cms.gov/ombudsman.
■ Call 1-800-MEDICARE (1-800-633-4227). TTY users should call
1-877-486-2048.
My sister has POA and asked for Mom’s records. They said it would take five to ten days to get them! I called Medicare yesterday, but I didn’t have Mom’s Medicare ID numbers then. I’m getting on a plane in a hour, and tomorrow when I have Mom’s Medicare IDs I’ll get back on the phone with Medicare and find out more. I doubt that the facility is entitled to withhold Mom’s records from us for over a week.
I’m not suspicious that Mom is getting bad care. She is improving. My sister saw her at rehab yesterday and reports she was happy and using some sort of hand-and-foot stationary bike. This is not a case of abuse.
But I don’t understand why this is adversarial. The question of quality of life for a 91-year-old with dementia is a delicate one. To be sure, Mom is improving, but is this slow improvement worth the life she is sacrificing now out of her small remaining store of mentally alert life? Why are these people saying that if Mom is discharged next week it will be Against Medical Advice?
When I said “suspicious”, I hope you don’t think it was about your mom’s care. I was thinking more in terms of the way they are holding her as a patient to gain reimbursement from Medicare. They have to have weekly meetings and report steady progress for them to receive Medicare reimbursements. What was the initial goal for your mom at the beginning of treatment, (it should be documented). Have they reached that goal? I agree that if your mom is requesting to return to her apartment, I would do what I could to make that happen and secure whatever services she would need to keep her safe. You may wish to contact her PMD to apprise him of the situation. Best of luck.
They had a meeting with my sister a couple of days ago. She asked them what the initial goal for Mom was. They couldn’t tell her. Improve, blah blah blah. I’m going to be on the scene soon, working with my very competent and determined sisters to do the best for our mother.
I think you’ll learn more on-site, CF. I thought Medicare A covers sub-acute as inpatient only. So her discharge isn’t necessarily an adversarial ‘against med advice,’ but may reflect that her course of care isn’t completed, technically. You may have to show she can be properly cared for at home, be fully safe. What I’ve seen talks about Medicare covering when, eg, a patient returns home but continues to rehab at a facility.
@ECmotherx2 excellent link for vascular dementia / stroke
@“Cardinal Fang” sounds like “mother fang” has excellent family support system
Regarding getting medical information and speaking to insurance companies -
Make sure all of your family members are listed as official medical representatives for Medicare - it’s a simple form. My sister, my husband and I are all listed for my mother it made things easier.
CF, an awful lot of conversations with staff at nursing homes and hospitals revolves around what Medicare will and will not pay for. I try not to get too frustrated with it, because most families won’t have the resources or desire to pay out of pocket for care, and the case managers need to make sure they get approval from the family before starting anything that might not be covered. Of course, they also have pressure from the owners/managers to provided as much care as Medicare will pay for. So, you have to listen closely to discern what decisions might be made differently if Medicare billing were not an issue.
I’m interested to hear how this works out - I’ve never heard of a case where Medicare coverage of past care could be affected by a change of care plan.
FYI, I am the POA and executor for my soon to be 99 yr. old aunt. I did not receive her 1099 from Social Security. I called to get a copy, only to discover that my POA was not recognized and they would not talk with me. They told me to go to a nearby SS Administration office with my aunt so she could sign the paperwork to make me a Representative Payee. Well, she is house bound and has dementia. I was told to present a letter stating such from her MD. It took about 2 hours yesterday for me to accomplish this. So, for those of you making the rounds with banks and other institutions as you try to safeguard the finances of your family members and ensure you are recognized as a legal representative, you may want to consider adding this on your list. Aargh.
ECmotherx2, when it was necessary to change my dad’s direct-deposit destination, I found that the easiest way to do so was to create an account on the social security website. Not sure that you could get an extra 1099 that way but it’s worth a try. Here in Brooklyn, a visit to the social security office is a day-long event so I was grateful to handle it online.