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.
You also mentioned that she cannot cook, etc. Medicare does not pay for assistance to do these task. Some Medicaid home health will do these tasks with funding from other elder care agencies. Otherwise she will need long term care. Refer her caregiver to aging and community services and get social worker involved ASAP
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
Not 100? 60 is even worse.
Maybe she got 100 because she had a supplemental insurance.
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
Depression is likely a very real factor.
The injuries occurred several months ago (winter) and I think the metal screws used for her ORIF's cause(d) very real pain. So pain is real.
As far as I can tell, she does do the quad setting and other exercises PT ordered. She does walk with the walker to toilet and down the hall to her kitchen, even a little farther, and back.
I think she'd be OK and would continue to progress if Burnout wasn't reasonably, understandably tired of putting in such long hours, and if she could continue to receive OT, but the agency doing her home health is saying she's progressed as far as possible. I think her coverage is running out, though, and that is the real reason for the agency pulling out soon.
She does need OT or to somehow learn to make a light meal, even if it's just microwaving a TV dinner and getting it to the table.
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.
Why was she degrading you, especially in view of the fact that you were saving her tons of money?
How would she have gotten by if you hadn't helped her? How did she get by Monday - Friday?
Is the Office of Aging through the state? federal? other?
If the patient is receiving private duty nursing, who is paying for that? Medicare doesn't cover PDN.
No, no private duty, just dressing changes and med set-up via Home Health visits twice per week.
No aides either except if she occasionally hires someone herself, which happens rarely.
Burnout (her relative) has been doing the bathing, laundry, shopping, and giving her 2 meal daily, taking care of the mail, pets, trash, bills, and everything else.
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)
I learned the other day that there are 60 extra days available per year, don't remember what they're called - some sort of supplemental days - but there are qualifying requirements, of course.
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.
If such a letter were written, it would be for her eyes only, as a suggested format of how to write a humble letter. I would never write to him, don't know where he is either.
SHE wants the wife to come. For free, of course. I have never intimated or agreed that wife would help and never would take wife to my job.
I have not done any unpaid work, nor do I have any intention of doing any, except to talk to a couple of Social Workers for info that I lack about options patients in these circumstances have. I just am feeling sorry for her and scared that America seems to let people suffer such horrible fear over something so basic as health care. Other civilized nations have somehow settled this problem but we have not, it seems.
No vets in her family to my knowledge, although that's a good idea.
I think she needs more than AL, although I learned recently that AL can mean just about anything from needing someone to assist you tying your shoe to needing total care, depending on the state, I think.
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.
Thanks for your post, but I am confused. What are you saying in your first sentence? Can you define SNF? Is it inpatient? Does Home Health by a licensed care count as skilled care? Not private duty in-home RN or LPN all day every day but visits by licensed nurses to do dressings, set-up meds, and do head-to-toe assessment a couple of times per week?
After a break from inpatient skilled care, of at least 60 days, are you saying she could go to a SNF again for up to 100 days?
Did you mean Medicare or Medicaid? She already has Medicare because of being past her 65th Birthday.
What would the Ombudsman do? What would Senior Services do? Is that state SS and Ombudsman or are they through Medicare? Or other?
I don't think anyone is abusing her financially. I have not delved into her finances and will not be doing that. it's probably a good way to go to jail, lose my license, and otherwise regret doing that. I guess she pays Burnout for shopping, maybe gas to carry her to the doctor.
I just skimmed after page one so this may be redundant. I'll share some of my (husband's) experiences with rehab and Medicare.
I'm not sure of the number of days Medicare will pay for this and that, but I do know that Medicare will not pay for "custodial" care (help with activities of daily living). AFAIK, the only insurance or program that will cover ADL/custodial care is specific "long term care insurance" and Medicaid.
My late husband had to have rehab and therapy, in-patient at a hospital (once), in SNFs (usually), and in the home many times during his last couple of years due to the effects of a previous stroke and deteriorating health and recurring pneumonia. Any hospitalization made him weak and required weeks of therapy before he was able to come home. Medicare will pay for in-patient therapy and for therapy received in the home, but the patient must be progressing in the therapy for another round to be approved. Medicare will not pay for custodial care, and neither do many medical insurance plans. For several months before I retired, we had to hire a home health care aide through an agency to stay with hubby while I was at work. This was about six years ago and it was $18/hour, all out of pocket. The cost of living in my area is relatively low. There were no family members who could stay with him during the day (all had jobs and families of their own), and we did not expect them to do so. I retired a year earlier than planned because he couldn't stay alone all day.
As most know, to qualify for Medicaid a person is only allowed so many assets. I don't know the limits, and it probably varies by state. (Hubby would not have qualified for Medicaid so that was never an option.) Medicaid, if the person qualifies for it, will pay for custodial care in a nursing home if the facility takes Medicaid, and probably for some in-home care; not sure on that. I believe they do look back at asset transfers, but honestly, that is not wrong when you think it through. People would not be able to transfer or hide assets in order to avoid paying for any other necessity, so Medicaid looks at it the same way. Nothing is "free," someone has to pay for it, and Medicaid has determined that's the patient's assets first, if he or she has assets. Yes, it would hurt big-time to have to pay a nursing home or assisted living out of pocket, but that's how it is. Many people assume Medicare or medical insurance covers custodial care, but it doesn't.
Therefore, if your patient cannot live independently but no longer qualifies for any kind of therapy or skilled nursing care (but simply requires custodial care) and has assets, she will have to pay for her care until she no longer has assets with which to do so and can qualify for Medicaid. That's what everyone in that situation faces. (I now have long term care insurance, but it's expensive and you have to get it while you're healthy.) We chose in-home care, but hubby mainly only needed help getting from a seated to a standing position and someone to make sure he took his meds and fix him a bite to eat during the day. He could walk with a cane and some careful effort. (It's scary how requiring just a little bit of assistance can cause one to be unable to be alone for more than a couple of hours!)
As for your involvement, you've already received good advice here. Social services need to be advising her; they always arranged for hubby's therapy and rehab after a hospital stay. Also, don't be too hard on her family. Most people cannot afford to quit their jobs to take care of a family member long term, and many patients would never expect nor want them to do so. I didn't read your OP before it was edited, so I don't know the specifics of her family situation, but that doesn't matter when discussing Medicare benefits.
In hubby's case, he always qualified for PT and OT at the level of disability that it sounds as if your patient still has, but he was a fighter and fortunately able to make progress until almost the end. Was she truly not progressing in therapy at all? In any case, I don't think her problems are ones that you can personally solve. You might be able to get the social services department at the hospital or home health agency involved. They should know what options are available to her. They deal with such situations quite frequently.
As they say, getting old isn't for wimps. sigh (Sorry for the wordy post.)
You need to pull back. This is not your problem to solve. I highly recommend removing yourself from this case. This woman appears to be a master manipulator. You need to keep the professional boundaries intact, and I fear you are dangerously close to crossing them.
Hoosier_RN, MSN
3,968 Posts
You also mentioned that she cannot cook, etc. Medicare does not pay for assistance to do these task. Some Medicaid home health will do these tasks with funding from other elder care agencies. Otherwise she will need long term care. Refer her caregiver to aging and community services and get social worker involved ASAP