Anyone Knowledgeable Here About Medicare/Insurance?

[Kooky Korky, BSN, RN]

I have a soon-to-be- former patient who can walk short distances with walker, has hard time getting back into bed.

Can toilet alone. Cannot do even the lightest cooking because she can't let go of the walker long enough to, for instance, make a sandwich or heat a can of soup. She can't reach out to the porch to get the mail.

When you take longer to heal than Medicare allows, when you are fast going through any reserves you had (to pay for utilities, food, mortgage, a helper for a couple of hours per evening for a couple of times per week, what do you do?

What do people in this situation do? Go live with friend or relative? Sell whatever they can sell and then become homeless and live under a bridge?

Get arrested and be grateful to be in jail? Say you're suicidal and get admitted to Psych?

How do the 100 days allotted by Medicare get renewed or extended?

I have suggested trying to learn resources, if there are any, by talking with a Medical Social worker and with a Case Manager but don't really know how to find these people except to start calling hospitals and insurers. Kind of hit and miss, no?

Pt could probably rent her spare bedrooms and her garage space, sell a car, sell jewelry, guns, furniture, or whatever she might have of value.

Any thoughts on this? Like why America, the greatest country on Earth, stinks when it comes to health care. I already know the answer - $$$$$.

Insurers' profits. I guess. Or am I missing something in my cynicism?

She never even offers to reimburse for food that people go out of their way to bring her, or for some small but nevertheless real expenditures at WalMart on her behalf. Does she conveniently forget or what?

The County I live in has an extensive Senior Services department, her County does not. I've thought about checking with various religious organizations and homeless shelters.

I doubt she qualifies for Medicaid and she says she can't afford to enter a facility. That seems to leave the old cardboard over the heating grate or the park bench.

Any help you can think of would be much appreciated.

[blondy2061h, MSN, RN]

First of all- there's a ton of details in here and you may want to reconsider that.

Secondly- her 100 days allowed by Medicare of what are expired? It sounds like she needs inpt rehab or assisted living.

[cleback]

Unfortunately, I think at least some people in this situation dwindle their resources until they do qualify for medicaid and then enter a long term care system. I dare say most people in nursing homes, except the truly fortunate, can't afford it but are receiving aid.

If it's a former patient, you seem to be very, very involved in her private matters. It may be hard to think objectively about realistic solutions as such.

[Kooky Korky, BSN, RN]

First of all- there's a ton of details in here and you may want to reconsider that.

Secondly- her 100 days allowed by Medicare of what are expired? It sounds like she needs inpt rehab or assisted living.

Yes, it is long. Thanks for reading it through and responding.

100 days that insurance covers before kicking you out because you have used up your 100 days. you have to know a little about Medicare to know this. I think you have to have an inpt stay of at least 3 days - or nights - , then you get 100 days paid by Medicare and your 2ndary insurer for Rehab, then they get PT to say you can get in and out of the tub, bathe, dress, etc. even though there is no tub even in the Rehab facility at all and you have certainly never been anywhere near it, then, if you don't challenge them, they put you out. I think that's how it works.

She does need something different than living at her own home. However Medicare and her other insurer won't pay because she used up her 100 days long ago.

And she can't afford the entrance fee to AL or Inpt Rehab. She has to come up with the money for these, and says she doesn't have the money.

So that is why I am wondering if she has to go bankrupt or get used to being homeless or???

[Kooky Korky, BSN, RN]

Unfortunately, I think at least some people in this situation dwindle their resources until they do qualify for medicaid and then enter a long term care system. I dare say most people in nursing homes, except the truly fortunate, can't afford it but are receiving aid.

If it's a former patient, you seem to be very, very involved in her private matters. It may be hard to think objectively about realistic solutions as such.

She's a current patient, soon to be former. It's hard to not hear when she talks to Burnout or when Burnout cries on my shoulder (not literally). Being involved in all this mess, however unwillingly, is one reason I HATE private duty nursing.

And don't forget - Medicaid has a lookback period- 5 years is it? i don't quite know how that works. But if Medicaid thinks you transferred assets to someone else's name within 5 years, they can and do deny you coverage because they think you're hiding assets.

[elkpark]

Doesn't your agency have a social worker who would be knowledgeable about the answers to your questions and be able to direct this individual?

[JKL33]

Your actual role in this scenario is to request a SW consult through your agency. Maybe visit SSA or other agency to gather information. If you have extensive senior services in your county, I don't think it would be out of line for you to visit some resources there and find out information that could apply to an individual in a different county (info about M'care, SSD, recommended lawyers, stuff like that) - - if you wish to volunteer time in this way.

I have sort of chastised a few coworkers before for being really angry that family members declined to come to the aid of some of our elderly ED patients. Coworkers can't imagine what kind of a sick, selfish individual doesn't come to the aid of their elderly family member when needs arise. Well - - sometimes it has to do with what all has transpired in the past 60+ years. It's very sad to witness but sometimes it is just no one's fault. Sometimes it's actually due to relationship choices the patient freely made earlier in life.

You can't allow yourself to be guilted into putting yourself in the sort of position you're talking about. As the sometimes "resident warn-er" I will add that these situations are often not safe for parties such as yourself in the midst of family dysfunction. What happens when you volunteer time and possibly personal funds to continue helping this lady and they find fault with what you do (or don't) do? What happens when it's not enough and they make a complaint about something? What happens when she deteriorates under your (unofficial) watch? Or her needs conflict with your/family's needs? You're still an RN and that will sensationalize whatever way this goes wrong.

I say you take a few steps to gather information and present it to them; names, entities, etc., where they can consult for help with their situation. Don't forget her PCP office (or the office of whomever ordered the services you are currently providing)!!

After these efforts, leave with a clear conscience.

[MunoRN, RN]

If it this point she cannot live independently and requires some level of nursing home placement and has too many current assets to qualify for Medicaid coverage for nursing home then she would have to a "spend down" until she qualifies.

[Kooky Korky, BSN, RN]

Doesn't your agency have a social worker who would be knowledgeable about the answers to your questions and be able to direct this individual?

Yes, there is one. I have spoken with her about this pt and she is planning to do a reassessment visit with her soon. She's working on getting a doctor's order for the visit.

[Kooky Korky, BSN, RN]

If it this point she cannot live independently and requires some level of nursing home placement and has too many current assets to qualify for Medicaid coverage for nursing home then she would have to do a "spend down" until she qualifies.

Being single, she is allowed to keep her house, she says. She has no car. I don't know and don't want to know what other assets she has.

I am not nearly as involved in her life as I might have seemed to be at first. It's just that she keeps c/o how hard it is on Burnout. I do think I need a different assignment.

I have never given or lent her money, have no intention of doing that. I am not involved in her finances whatsoever. I think that is not a good idea at all. And I don't run errands for her, like pick up stuff at the store even if I am going there. I just don't think it's good to get into these habits. It is hard, though, to resist, as previous staff have done this for her, she says. Now, with me there, poor Burnout has to do it all.

And I feel guilty, despite knowing I needn't feel guilty, wondering if it would be wrong to pick up her Rx or food or whatever if I'm going to that store already for my own personal biz. My job does discourage but not forbid this behavior.

I think they hope we will just do it and not mention it because it does help the clients. However, it exposes the workers to accusations of mishandling monies, might even bring driving liability if an accident occurs while we are running errands for patients.

I really appreciate all the good advice I have been given so far. Many thanks to all!

[Kooky Korky, BSN, RN]

Your actual role in this scenario is to request a SW consult through your agency. Maybe visit SSA or other agency to gather information. If you have extensive senior services in your county, I don't think it would be out of line for you to visit some resources there and find out information that could apply to an individual in a different county (info about M'care, SSD, recommended lawyers, stuff like that) - - if you wish to volunteer time in this way.

I have sort of chastised a few coworkers before for being really angry that family members declined to come to the aid of some of our elderly ED patients. Coworkers can't imagine what kind of a sick, selfish individual doesn't come to the aid of their elderly family member when needs arise. Well - - sometimes it has to do with what all has transpired in the past 60+ years. It's very sad to witness but sometimes it is just no one's fault. Sometimes it's actually due to relationship choices the patient freely made earlier in life.

You can't allow yourself to be guilted into putting yourself in the sort of position you're talking about. As the sometimes "resident warn-er" I will add that these situations are often not safe for parties such as yourself in the midst of family dysfunction. What happens when you volunteer time and possibly personal funds to continue helping this lady and they find fault with what you do (or don't) do? What happens when it's not enough and they make a complaint about something? What happens when she deteriorates under your (unofficial) watch? Or her needs conflict with your/family's needs? You're still an RN and that will sensationalize whatever way this goes wrong.

I say you take a few steps to gather information and present it to them; names, entities, etc., where they can consult for help with their situation. Don't forget her PCP office (or the office of whomever ordered the services you are currently providing)!!

After these efforts, leave with a clear conscience.

You are so right. No good deed goes unpunished, that I have already learned in life, LOL.

And yes, we are often not knowledgeable about how relationships have gone in the past, what grudges have been existing for decades. And sometimes people truly want to help but time and other obligations, like work, kids, one's own health, just don't permit. I don't blame Burnout. She has a lot of other obligations and she has, as far as I know, been a tremendous help for the past few years when this pt had another long course of illness and during this current illness.

[hppygr8ful, ASN, RN, EMT-I]

To answer your question. Medicare does not allow for 100 days of coverage after an acute hospital stay. After and accident or illness that result in an acute hospital stay Medicare cover's 60 days of post acute care to help you recover and receive rehab. It should be noted that during the rehab phase if you stop making progress with rehab Medicare may stop paying. Medicare does not cover care that is considered custodial... ie.. Bathing, cooking, transportation etc...If your rehab stay goes beyond 60 days you must have secondary insurance to cover additional cost. It is a sad state of affairs that people live under the assumption that Medicare will pay for their final expenses. In most cases people who have not planned for their care are forced to go through all their assets then qualify for Medicaid.

Hppy