maze

The Maze of Medicare

Sometimes it amazes me (no pun intended) how I stumble on this information.  I shouldn’t have to stumble. This information should be readily available and it’s not. I hope that, through this blog, you will pause and ask questions when you encounter a situation so you can learn about your loved one’s Medicare benefits in a more expedient manner than I have.

My dad was on Medicare Part A last fall after he came back from rehab after his hip surgery. He was getting physical therapy and nursing services for wound care. When he went into the hospital this last time, I learned about a specialized Physical Therapy practice that had particular expertise in Parkinson’s so I made a note to myself that when he came home, I would sign him up for their services.  What I learned was that because they came into the facility, they fell under “Home Healthcare Services” according to Medicare, which falls under Part B.

You cannot access Part B services at the same time as Part A services.

So I had him discharged from Part A because I really wanted to try out Dynamic Home Therapy, the specialized therapy provider.  I was not disappointed.  They provided superb therapy, both physical and occupational therapy services and went even further to suggest that he look into a different wheelchair. I was exceedingly pleased I had made that decision. Once he was discharged from Dynamic Home Therapy, I figured I would eventually move him back onto Part A for skilled nursing services as he always seems to have a skin tear that requires nursing services.

Last week, I finally got the paperwork together and today, the nurse stopped by to tell me that she would be starting next week and would be providing him with wound care.

And this is the KEY THING SHE SAID: She casually mentioned that when she opens a new “incident report” it comes automatically with 20 sessions of Physical Therapy!

There is no dollar limit like there is with Part B but there is a 20 session limit PER INCIDENT. She can re-certify him every time there is a new incident and, in my dad’s case, simply having Parkinson’s would qualify him to stay on because there is no longer a need to show improvement. And, he pretty much always has some sort of skin tear so nursing would always be able to re-certify him for that. This means he will have ongoing physical therapy. There is an in-house therapy team right where he lives which is convenient. It’s not the specialized therapy that Dynamic Home Therapy provided me, but I look at it as a way for him to continue to get structured one-on-one exercise 3 times a week, compliments of Medicare Part A.

Your welcome for the information.

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Trying to Out Run the Inevitable

boulder

Lately, I have felt like I am trying to outrun a boulder rolling down the hill right towards me.  I am trying to outrun it, to keep just ahead of it, averting disaster.  This is the life of a caregiver, but it is particularly evident as time marches on.

In the past month, my father, who has a plethora of health issues, including Parkinsons, Dementia, Aphasia, cardiac problems, now has another couple more to add to his list: Bladder Cancer and another hip surgery because the last one didn’t heal properly. Yesterday I made the decision to go back in for corrective surgery to his hip in hopes that it alleviates the pain he has been in. Before I can take him into the hospital, though, I have to take him to the urologist so he can cauterize the tumor growing in his bladder.  We just found out that he had a tumor and since he isn’t a good candidate for surgery, we opted to cauterize it periodically to try to stay ahead of the cancer growth.  Once he goes in for his hip surgery and then on to rehab, Medicare’s rules don’t allow him to go outside for any doctor appointments, because once you leave skilled, they won’t let you back in without considering it a new episode (which would require another 3-night hospital stay). SO….to avoid that, we are going in to take care of the tumor and then HOPE that it won’t grow TOO FAST while he is receiving rehab because he won’t have another chance to see the urologist for 2 months.

We also have to get him in to see the Movement Disorder’s doc before he leaves for the hospital – he hasn’t been seen by him since last December.  Why? Because he unexpectedly fell and had to go in for hip surgery #1. Need to squeeze that in as well.

Hence the feeling of trying to out chase the boulder.

I am so angry about his hip.  Something to keep in mind if your loved one has to have hip surgery – particularly if they also have dementia.  Make sure you know ALL the details before you agree to anything.  I thought I had asked all the right questions.  When he fell last time, the doc said he would recommend the least invasive type of surgery, where they simply insert screws to help tighten up the fracture he had suffered (his was a non-displaced fracture).  I asked if the rehab would be easier because it was kind of laborious when he had his other hip done, although the outcome was excellent.  He said it usually was.

The VERY IMPORTANT PIECE OF INFORMATION HE DIDN’T SHARE WITH ME WAS that this type of surgery requires an individual to maintain a 50% weight bearing status for SIX WEEKS.  

Had he told me that, I would have told him that this won’t work with someone like my dad, who cannot remember anything.  As a result, the rehab was a disaster.  He was forced to be bedridden for 4 weeks (which is terrible for someone with Parkinsons, where exercise is truly an elixir) and then two weeks later, Medicare discharged him for failure to make progress. Nice, eh?  If the doc had shared that tiny piece of information, we wouldn’t be where we are today, going in for his THIRD hip replacement surgery.  No one should have to go through this, particularly an almost 90-year man. So the moral of this story is make sure you ask about the weight bearing restrictions, or for that matter, find out if there are any restrictions post surgery.  Then make the decision based on what you think your loved one can handle.

 

 

 

Oy is right. Those 100 days of skilled nursing may be a mirage thanks to new Medicare Initiative.

Oy

During this journey, I have felt as if I keep tripping over new information – critical information that families should be made aware of, but instead I find out the info by accident.  Apparently just a couple of months ago – a.k.a. before my dad fell and broke his hip but AFTER he fell and fractured his pelvis – Medicare expanded a new initiative they had started a couple of years ago.  This year, the expansion INCLUDED orthopedic practices and specifically hip and knee replacements.

The way it USED to work is when you fell and had to have hip replacement surgery, you would receive up to 100 days of skilled care, as long as you were making progress in therapy (and also assuming you had been out of the system for 60 full days – see prior blog post).

Now, with this new initiative, Medicare has decided in advance roughly how long it should take to rehab a person who has hip or knee replacement surgery.  Medicare takes the time they think it takes a 90-year-old and the time it takes a 50-year-old and then averages the period into something in the middle. They do not take into consideration any co-morbid conditions, which most 90-year-olds have, nor do they consider the additional complication of Dementia.

So, for the purposes of this explanation, let’s assume Medicare says it should take a person 20 days of rehab to recover from hip surgery….if the nursing home disagrees, and keeps a patient on for longer, then the Orthopaedic practice gets less money.  Next time they have a patient to send, perhaps they won’t choose that nursing home.  The nursing home, which was trying to do the right thing now goes out of business. Furthermore, this is a system that ultimately does not benefit the patient.

Let me explain further.  In a bundled payment environment, Medicare has decided, in advance, how much a hip replacement should cost, including hospitalization, skilled nursing, and home care. The physician’s practice is given a bundled payment for all of those services and then they hire a management firm (in my case, Remedy out of CT) to manage the various vendors involved in my father’s care. The incentive on paper is to make sure that no one is keeping my father on too long to milk the system (I am guessing).  The sad byproduct of this, of course, is that patients like my father, who may need a bit more time than the average, due to his co-morbid conditions, will end up two ways:

  1. He will be pushed out of skilled care before he is fully ready and,
  2. The nursing home, which has done an excellent job with my dad will be penalized if they keep him on until he is fully ready

And the real victim, of course, is the patient:  my dad.  If they discharge him before he is ready, he will be back into the system sooner than later.

3 Things I have Learned From Taking Care of My Dad

lefthand

When you take care of the elderly, it is 100% on-the-job-training.  There is no manual.  And what you encounter…well, you just can’t make this stuff up.

A little background first…my dad has Parkinson’s Disease.  He had been treated with the standard Parkinson’s meds for years but this past summer, after his first fall and fracture, we took him off this medication as we thought it may have been the cause of his fast onset of dementia-like symptoms.  At the time, we were operating as if he had fallen into a state of temporary delirium, something that is quite common with the elderly after the trauma he had experienced with this fracture and subsequent hospital stay.

The symptoms didn’t go away, however, but his Parkinson’s symptoms came back with a very loud roar, so last week, we re-started the Parkinson’s medication.  With Sinemet, the gold standard in Parkinson’s meds, a patient takes a dose throughout the day.  As the medication wears off, the symptoms return.  Therefore, when you are incorporating rehab into your day, you’ll want to time your session shortly after another dose of the medication is taken.  Not rocket science, yes?

LESSON #1:  DON’T ASSUME THE LEFT-HAND KNOWS WHAT THE RIGHT-HAND IS DOING

I found out, quite by accident, that the therapy folks were not coordinating the timing of their sessions with my dad with the nursing staff, who were giving him his medication.

LESSON #2: YOU HAVE TO BE OVERSEEING EVERY DETAIL OF YOUR PARENT’S CARE. YOU ARE THE KEEPER OF THE “BIG PICTURE.”

And finally, it is, I believe, impossible to take care of your mom or dad from afar.  I did this for about 10 years before I finally put my foot down and moved him across the country to be near me. You cannot possibly manage someone’s care properly unless you see them frequently, attend doctor’s appointments with them etc.  I also believe that after the age of 75, it becomes nearly impossible for a person to consider moving.  They begin to operate their lives using visual cues more and taking them out of their familiar environment can really throw them cognitively.  We are all living longer and eventually, we will all be dealing with this period in our lives.  My advice…and one I plan to follow…is to move near your kids (or whomever you have designated to be your healthcare proxy) before the age of 75.  That way, you get to enjoy being near them before you become so needy.

LESSON #3:  MOVE YOUR PARENT CLOSE TO YOU WHILE YOU CAN STILL ENJOY HAVING THEM NEARBY

My father never wanted to move. He gave me all the standard lines:

I have lived here for over 50 years;  my friends are all here;  I’d be a burden.  The usual statements you are likely to hear.

Here’s the truth:

  1. If you live long enough, as my dad has, many of his friends will pre-decease him.
  2. If you  move when you are still young enough, you’ll have the opportunity to make new friends.  If you wait too long, and you develop dementia, or Alzheimer’s, you won’t be making friends as you will be too compromised to do so.
  3. The burden story?  We all become a burden to our kids at some point.  It’s part of the circle of life.  It would have been SO MUCH BETTER to have had my dad living near me for at least 5 years prior to his slide into dementia.  Taking care of him without the benefit of those happy memories to draw upon – well, that’s where it feels like a burden.

48 Hours. It’s A Running Theme.

48hours

One thing I have noticed during this experience is that facilities (whether they be a hospital or a rehab center) seem to think that 48 hours is enough to make a major decision.  That is the amount of time they are required to give you to determine where you’d like your loved one to be transferred to next, once they are ready for discharge.

TRUST ME.  IT’S NOT ENOUGH TIME. Be proactive. Start your research the minute your parent goes into the hospital or into rehab, NOT when they are about to be discharged.

Here is a list of things to keep in mind when looking for a rehab facility.  Wish I’d had this list.

Questions you should be asking of the facility:

  1. What is the number of aides to patient ratio?  Look for a 6:1 ratio or better.  Anything fewer, your mom or dad will be waiting a long time to be helped to the bathroom. Remember, it’s not the number of nurses, or med tech’s you are looking at…it’s the number of direct service aides.  These are the people who are on the front line for taking care of your mom or dad.
  2. This may be a silly question to have to ask of a nursing home, but trust me ASK IT. You’ll want to confirm that all the bathrooms in the rooms are handicapped accessible. I found out the hard way.  The nursing home where my dad is does not have wall mounted handrails.  They only have “handlebars” attached to the toilet.  That is not sufficient for my dad’s needs.  I never in a million years thought I’d find a nursing home without handicapped-accessible wall-mounted rails.  I did. Lucky me.
  3. Will my parent have to share a room?  Again, don’t assume he/she will have a private room.  I did and found out that not all nursing homes have private rooms.  If they have shared rooms available, that is what Medicare will cover.  In our case, we have to pay $40 to upgrade to a private room.  In the last two places he received skilled rehab, he had a private room, for which Medicare paid.  I assumed (wrongly) that this place would be the same.  The way it works is that if the facility ONLY offers private rooms, then Medicare will pay for the room.  If the facility offers an option of a shared room, then they will only pay for a shared room. If it is important to you for your parent to have the privacy of a private room (it was for me), know that you may be charged a fee.
  4. Ask if there is a walking path or sidewalk outside the facility that is wheelchair friendly (if your parent is chair-bound) so you can get your mom or dad outside for fresh air.  Again, I assumed there would be because the last place my dad was had many different outside areas I could walk him to  get some Vitamin D and fresh air. This cannot be underestimated.  When a person is confined to a nursing home, it can be a very dreary existence.  Having the opportunity to get outside is liberating for both your parent and for you.
  5. If, your parent has had more than one hospitalization in recent months, make sure to get the hospital discharge papers from each facility and hand deliver them to the nursing home.  It is the protocol for the referring hospital (meaning only the last one your parent was admitted to) to send over discharge papers.  In the case of my dad, I found out THREE days into his stay at the rehab facility that they had NO IDEA that he had had hip replacement surgery 2 weeks prior.  They thought the patient they were receiving was there after hospitalization for GI ulcer (the side effect to the blood thinners he was put on after his hip surgery).  You can imagine the type of treatment he was receiving at the rehab center.  They were asking him to do things that he physically could not do;  they were roughly handling transfers from the chair to the bed, etc. It was only when I started complaining about the treatment, that it surfaced that they had a major whole in the information they were operating on.
  6. Don’t rely solely on the Medicare.gov site and their nursing home compare tool.  And don’t rely on US News and World Report’s Best Nursing Homes issue. Look at those resources but also talk with local doctors who have patients in rehab facilities.  The most important thing you want to ascertain is how good is the therapy your parent will receive.  That single thing represents the direct correlation to shortened stays in skilled nursing. Remember, the hospital social worker is not allowed by law to endorse a particular facility, so although they will help you find out if there is a bed available and to get all the paperwork transferred, they are not a good source for where to send your parent.

And finally, visit your mom or dad often.  It is a proven fact that residents whose family visit often get better treatment in these types of facilities.  Visit at different times in the day.  Speak up if you see your parent (or even another resident) not being attended to.  At the end of the day, this is a very tough job these people do day after day.  They want to do what is right but sometimes they are overwhelmed by the needs of the residents.

Thank them often.  

And then thank them again.

It will make a difference in their lives and in your mom or dad’s life.

Become the multiplier. Share this knowledge.

knowledge

Three days into the new skilled nursing facility and I have already:

  1. Called the prior place my dad was receiving rehab before his recent trip to the hospital and pleaded for them to take him back, and
  2. Put the pieces of the puzzle together to figure out why my dad’s experience where he is currently placed was so much worse than where he had been.

FIRST LESSON TODAY:

Never, ever, ever, ever (have I said that enough times?) assume any prior knowledge by ANYONE. I had assumed that when my father was sent over to this new skilled nursing facility, that all his prior medical history came with him.  I had assumed that the facility knew that my dad had fractured his hip, that he had a recent hip replacement and that, as a reaction to the blood thinner the doc placed him on, he had an upper GI bleed. After all, both hospitals he had been at were a part of Mainline Health and shared computer systems.  They are a well-respected health care system of doctors and hospitals in the area where I reside.

What I observed during the first 3 days of his time at the new facility was seemingly no deference to the fact that he had had recent hip surgery.  He was being asked to physically do things that I knew he was incapable of doing (yet).  They were transferring him from chair to bed, from chair to commode as if his only problem had been an ulcer. In one case, during a transfer from the wheelchair to bed, I prevented my dad from hitting his head on the bed rail when an aid flung him onto the bed! When I witnessed this sort of stuff, it sent shivers up my spine as I wondered if this might be my fate some day. (Kids, I hope you are reading this blog and taking notes!)

What I learned this morning was horrifying to me.  I still am mystified as to how this can happen in the today’s world of electronic medical records.  Apparently, this is common.  So, folks, pay attention here.

LESSON #2

It is the protocol for a hospital to refer a patient to a skilled nursing facility with discharge papers from JUST THAT HOSPITAL.  In my father’s case, he had recently been at TWO hospitals:  one for his hip replacement and one for his GI ulcer.  Apparently, the first hospital doesn’t release any data to the skilled nursing facility because they didn’t make the referral.  SO….essentially, my father was sent over to rehab and the receiving party assumed he was there after an ulcer ONLY.  The only way to get the information about the first hospital is for the family to request it.  That would have been fine IF SOMEONE AT THE SKILLED NURSING FACILITY HAD TOLD THE FAMILY!!!!!!!

Once I realized there had been a very large gap in the information provided to the skilled nursing facility, I sat down with the Director of Nursing and worked out a plan.  We moved my father to a private room (which we have to pay the difference for privately –  this is the subject of my next blog post, coming soon!) and moved him to the dementia area, where the staff has training in how to interact with dementia patients. I am hoping it will be smooth sailing from here, but I have learned that during this phase of life, that’s a bit optimistic.  I’ll take even just a week or two off from the drama.

How the System Seems Stacked Against the Patient.

things

I wish I had a crystal ball.  If I had one, I would have known that dad would only be in the hospital for 4 days. When dad was rushed to the hospital on last Monday with internal bleeding, he had lost about 25% of his blood volume in one day.  When I arrived at the emergency room, he was almost completely unresponsive and pasty white.  All I was able to get out of him was a response to Dad, it’s Barbara.  I am here.  Can you hear me?  He responded “yes.”

I thought this was it.  The doctor said he was in a life-threatening state and that I should call family. Again, the questions were thrown at me.  “Do you want us to resuscitate him?  Put in a breathing tube?”  It all happened very fast and it was frightening.  I was doing this all alone.  The rest of my family is up in New England and my kids are both living out of the State.  It is during these times that the words “Stay Strong” have the clearest meaning.

Later that day, I got a phone call from the skilled nursing home dad had been at for 10 days receiving rehab.  He had made really good progress there and both my husband and I felt really comfortable with the care and attention he was getting.  The place was also very well maintained and on a stunning piece of land so there were peaceful places to take dad outside on a beautiful day.  The facility called me to tell me that because dad had been brought to the hospital, Medicare would stop paying for his bed at the skilled nursing facility within 24 hours.  If I wanted to, I could private pay for that bed to hold it.  The cost would be $325/day.

I thought about it for a millisecond and responded “no thank you.”  I didn’t know what was happening to my dad at that time, how long he’d be in the hospital AND he was already paying $4500/mo to “hold” his spot at the assisted living place he had been living before his hip surgery.  So I couldn’t see paying for THREE places at once – the hospital, the assisted living apartment AND the skilled nursing bed?  So I said, ” no thanks.”

What I should have done is slowed myself down.  The skilled nursing facility certainly wasn’t pressuring me to make a snap decision.  They said I could take a few hours to get back to them and think about it.  That’s what I should have done.  Buying a little bit of time would have given me more time to get a handle on exactly what was going on with my dad, what the hospital planned to do about it and would have given me a better gauge as to how long he might be there.

Fast forward to his discharge date and, of course, the place he had been receiving rehab no longer had a bed available and so my poor dad had to go to yet another rehab facility.  This one isn’t nearly as nice a place, although I think the rehab seems to be just as top notch. And at the end of the day, that is the most important thing he needed.

For most people, a different rehab facility isn’t a big deal.  For those dealing with dementia, as my dad is, it can be extremely stressful.  He now has to get used to all new surroundings (again), new people (again) and essentially restart his therapy from the beginning (again).  Not easy for any elderly person, but for those with dementia, it is very very difficult.  Again, the system seems stacked against the patient, rather than working for the patient.