Anyone Knowledgeable Here About Medicare/Insurance?

[Kooky Korky]

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.

[brandy1017, ASN, RN]

You sound kind-hearted, but also over-involved in her care. You are a nurse paid by your employer, not her friend or family. Frankly, I feel you are being manipulated by the patient who is trying to coerce you to care for her for free. I have cared for a dear loved one, but I was never in the capacity of a paid caregiver. I have seen a coworker get involved with a patient as a friend and it didn't turn out well. The ex-patient got angry about some perceived wrong and threatened her with retaliation at her job.

I would advise you do your job and when it is over you let go. It sounds like she can't care for herself at home. Most likely the patient will end up back in the hospital at some point either from a fall or because the family is too overwhelmed to care for her and she will eventually end up in a nursing home and have to give up her house which she probably should do already.

Medicare does pay for respite care for family caregivers, but only if the patient is in hospice and it doesn't sound like that is the situation here.

[CX_EDRN]

You sound kind-hearted, but also over-involved in her care. You are a nurse paid by your employer, not her friend or family. Frankly, I feel you are being manipulated by the patient who is trying to coerce you to care for her for free.

That's the first thing I thought as I read your post. You sound like you have a lovely heart and while this patient does need a higher level of care, she is also going to continue doing what she's doing until someone puts their foot down and says no. She has options- trying to reconcile a relationship, selling assets, etc and yet she does none of that. Why? Because she is fine with things the way they are. It must be incredibly hard to lose your independence but you also can't burn out everyone around you in order to keep it.

Change your assignment. You have done all you can for this lady, probably more than others would have done.

[Neats, BSN]

For Medicare coverage to kick in you need for SNF;

If your break in skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new hospital stay doesn't need to be for the same condition that you were treated for during your previous stay.

If your break in skilled care lasts for at least 60 days in a row, this ends your current benefit period and renews your SNF benefits. This means that the maximum coverage available would be up to 100 days of SNF benefits.

You have a great deal of knowledge about this person. I think the best thing to do is contact the state Ombudsman and senior services. It maybe this person needs ALF or SNF assistance. Most people do not want this because they will end up private pay if they own a home until they meet the Medicaid criteria. Basically they sell the home, pay private ALF or SNF room rates and then the social worker helps apply for the Medicare.

What usually happens in these scenarios you have described is the patient's family robs them blind, the patient is injured in the home and then goes to SNF. People have no ideal how hard it is to be a caregiver in the home.

[balistic]

It seems like she is going to have to sell her house and use that money for her care. Hopefully this will give her money for an ALF. If her husband was a veteran, she may qualify for some financial assistance once in an ALF, as well.

Agree with others- you need to take a step back. Do your job, don't get over-involved. Request a social worker eval from the home care company.

Do not write a letter to her son. That is a huge overstep. And, for God's sake, don't take your WIFE over there with you. HUGE HIPAA violation. Don't cross over the professional line. Don't go when you're not being PAID to go. Yikes.

[Mavrick, BSN, RN]

OP you have revealed WAY too much about this patient on a public website.

I had to stop because I felt like I was invading their privacy by reading any further.

As PPs have stated you may have good intentions but you have to keep professional boundaries.

[CharleeFoxtrot, BSN, RN]

You sound kind-hearted, but also over-involved in her care. You are a nurse paid by your employer, not her friend or family.

Exactly, while your heart is in the right place you are waaaaay over the line here. Secondly, I debate the wisdom of your sharing all these personal details on a public forum.

[Hoosier_RN, MSN]

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???

You have to have 3 nights (3 midnights crossed) of a qualifying stay inpatient at the hospital, with need for rehab noted. Then, you get 100 days for a year if you have not been admitted to the hospital for the last 90 days, and d/c dx cannot be same as any in last year used for rehab or does not qualify. There is no extension past 100 days. After that, or outside of that, either private pay or dwindle resources to qualify for medicaid. I did LTC/rehab for years, that's the long and short of it. And yes there is at least a 5 year look back period depending on the state (each state sets conditions for their program)

[Hoosier_RN, MSN]

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

Yes, MCR is for acute only, does not pay long term once progress stops

[LovingLife123]

She needs to sell her home, plain and simple. She then uses that money for AL and once that is depleted, she gets Medicaid. Don't get Medicare and Medicaid confused. Medicare is not for long term care.

[KelRN215, BSN, RN]

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.

If the patient is receiving private duty nursing, who is paying for that? Medicare doesn't cover PDN.

[AnnieOaklyRN, BSN, RN, EMT-P]

Is this patient really in need of all this help, or could she be in a depressive state and not want to help herself? I think what needs to be addressed is the cause for needing help, other than the accident. I think she needs PT for sure and someone to push her a bit to start living independently again.

I am not sure at what stage of her injuries she is in, but if she truly needs this much help because of physical limitations she does not yet belong at home.

Annie

[monkey205]

I was in the same personal caregiver situation but with a relative who has TONs of money to pay for care but would rather guilt one into doing for her. She actually refused home care after a fractured hip as she figured I would be there. I drove 100+ miles every weekend for years and finally I blew because of the subtle degrading remarks she made every week finally got to me. I had to walk away due to the burnout and abuse. Please refer her to social services or office of aging. They can set up meals on wheels and other assistance from possibly volunteer, etc. The Burnout one in this story should not be pushed any more; as for the other family members, you can't change their circumstances. It is a very unfortunate situation but not your responsibility. Learn to live guilt-free or it will eat you up inside.