Question about LTC facilities that do not accept Medicare

Advanced Practice Columnist / Guide · Apr 14, 2012

There are conditions for Nursing homes to admit patients under Medicare. A simplified way to understand this process is that admission under Medicare to a nursing a facility requires that the patient be transferred to the facility after a qualified hospital stay (minimum of 3 days) and will require skilled nursing care. Skilled nursing care can include need for rehabilitation services (PT, OT), need for intravenous medications such antibiotics, and a degree of medical instability that requires frequent physician visits (or non-physician provider such as NP and PA). It sounds like your grandfather does not qualify for a Medicare admission as he was being admitted as a resident from home.

Some nursing homes are certified for Medicare but not for Medicaid. In these homes, the residents are expected to either be discharged home after the maximim of 100 days of Medicare stay (for rehab, IV meds, care under the physician), or start paying out of pocket for their stay under a non-skilled nursing home resident basis. Some nursing homes admit both Medicare and Medicaid residents. Medicaid will kick in for residents who qualify for it based on need. Typically, a resident will qualify for Medicaid if the person lacks financial resources to pay for a nursing home stay and all financial assests have been consumed. It sounds like your grandfather also does not qualify for Medicaid.

I don't think it's necessairly bad for a person to be admitted to a nursing home that only accepts private pay. There aren't many places like that anymore except for ALF's which are technically not nursing homes. Such nursing homes are probably unprofitable because not many seniors have a great deal of financial resources to afford such a place.

itsmejuli · Apr 14, 2012

Wouldn't it be better to move her closer to you and your family?

SuesquatchRN, BSN, RN · Apr 14, 2012

If the place doesn't accept Medicare or order meds it is probably an assisted living, not nursing home.

Juan covered it. Medicare pays, generally, for skilled rehab, for I think 120 days total a year. They do not pay for everyone. You will more than likely have to spend down your grandmother's assets before she's eligible for help via Medicaid.

And get her closer, as Juli suggested. She will get better care if the family vsits - not nags, but shows up frequently. And if she HAS any assets you can hire private sitters and go set up a med box once a week. And she really needs to be closer if it can be managed.

Hugs.

Not_A_Hat_Person, RN · Apr 14, 2012

I worked in assisted living, and I had to place my mother in a SNF, so I can answer some of your questions.

So, to make a long, painful story short, my grandfather very suddently and unexpectedly passed away and he was the primary caretaker for my grandmother, who has Parkinson's. She is in the early stages, I would say between I and II.
We are looking at nursing homes and assisted living facilities for her. She needs extensive assistance with her meds and is forgetful, so I think any independent or even assisted living is out of the question.
One of the places I researched does not accept Medicare and thus does not have a Medicaid rating. What does this mean? Is it good or bad? Is it a red flag? Would you put your grandmother is a place that doesn't accept Medicare?

The facility I worked for didn't accept Medicare. All residents were private pay. Some used LTC insurance. It isn't a red flag, unless the facility has been banned from accepting Medicare.

The other problem I have is that this place does not provide people's meds for them. You have to supply your own. The only relative she has in the area is turning out to not be terribly reliable. She takes so many medications and she doesn't have a primary care physician to oversee this kind of thing. I'm really concerned that her prescriptions will run out, and then what will happen??

Do you mean no one administers meds to residents? Medication management was an optional service at the facility where I worked. Those meds were kept in the med room and given out by med techs and nurses.

Residents who signed up for medication management still had to provide their own meds. The facility had a contract with a pharmacy, which made deliveries daily and maintained the MAR. Residents could use that pharmacy or an outside pharmacy. About half used an outside pharmacy.

The vast majority of outside meds came by mail. For the rest, a relative would drop a bag of meds at the nurse's station every few months. Mail-order refills were either automatic or done by staff. Large pharmacy chains were very good about scheduling refills. The worst pharmacy for refills was the VA. Re-ordering narcotics was a HUGE PIA, regardless of pharmacy, after the DEA decided LTC nurses couldn't order refills without the MDs permission.

Since your grandmother has a chronic illness and lots of meds, the facility may require a PCP. They may contract with an MD, or with a group of them, but she would still have to choose one. They may also require a Health Care Proxy and an Advance Directive.

Any advice is appreciated. I'm not terribly familiar with the placement process, we are all grieving, and it's incredibly difficult to try to help from 8+ hours away. I want to be a good advocate for my grandmother and I don't want her to end up living in someplace shady.

The best way to advocate for your grandmother is to be there. Call or visit the facility frequently, preferably at odd hours or on the weekend (they can't restrict visitors unless the resident requests it). If that means moving Grandma closer to you, check out facilities close by. Talk to the staff. I had to manage my mother's care for 4 hours away, and I was geographically her closest relative.

Morainey, BSN, RN · Apr 14, 2012

Thanks for the replies, everyone. It really helps a lot.

I suggested moving her closer to us - she'd have 4+ close relatives nearby versus the one - but my dad objected, because he thinks she wants to stay in the same geographical area (which to me, is not so important) and because it's too cold for her (up here in New England). Now, imagine me, rolling my eyes.

The facility will pass meds - but you have to supply them. As someone mentioned, someone would have to show up with a bag of meds. My serious concern is that this won't happen.

The place that it looks like she's going to be placed in also wouldn't show my family their dementia/memory care unit on the tour. Seems shady to me, maybe because they don't prospectives to see the area, but I think it's fairly obvious that she is not appropriate for assisted living.

Luckily we are fortunate enough that she would be a private pay type of situation. In this case, I think she deserves the finest care that we can find, and I know in my heart my grandfather would want it that way. I'm trying to vote down the non-Medicare-accepting place, because both myself and my mom just don't have a good feeling about it, but it's up to the executor and they don't feel the same way. Sigh. I feel very powerless. I've made my opinion clear to my family, and they do listen, but it doesn't affect anything.

Esme12, ASN, BSN, RN · Apr 15, 2012

I am so sorry for your loss...:hug:. Everyone has explained things to you very well. My only advice is to get her closer and if you don't have a good feeling about a place....my experience is to listen to the inner voice.

KateRN1 · Apr 15, 2012

I'm so sorry for your loss and for the additional family issues this has created for you. Please consider hiring a Geriatric Care Manager to assist with your grandmother's needs, including placement and ongoing care needs. Visit www.caremanager.org for more information and to find a certified care manager in your area. The cost can be expensive, but the peace of mind is completely worth it and most likely equal or less than the cost of dealing with ineffective family members who don't do what they say they will. Best wishes to you and your family.

Whispera, MSN, RN · Apr 15, 2012

Since you have to supply meds, you (your family) might consider ordering them through a company that supplies 90 days'-worth at a time and delivers them to the facility, whichever facility you choose. That would mean you would have to remember to order but you wouldn't have to go there to deliver them. Also, if she's stable on her meds, getting them 90 days at a time is logical, and also is a whole lot cheaper for most meds.

I think it's nice that your dad doesn't want to take her out of her home geographical area, since he feels it would be hard for her. I hope someone talks to her though. Maybe she'd prefer to be by family rather than to stay where she is now, especially since her husband is gone. It might be hard for her to be without him, and if she has few people to visit her where she is now, that can be tremendously lonely at a time when she's likely to feel very, very lonely anyway. Sometimes, too, it's a matter of making the logical choice...the one that's best for the person involved and all those who care about her.

Places with dementia/memory care sometimes don't give tours to groups of people because it's hard on the residents to have strangers walking through. This place won't show anyone the facility?? I think I'd push for a tour and see if they allow at least one or two of you to see the place. There's no way on earth I'd accept a place sight-unseen. I'd also want the facility to give me some references of family members of residents I could contact, to get their opinions of the place. It's simple for them to call those family members, ask their permission to give you their names and numbers, and then to give them to you.

Warm hugs to you on your feeling of powerlessness. All you can do is advocate for your grandma, and I think you're doing that, so kudos to you. Keep on doing it!

How about someone to live with her, or check on her a few times a day, so she could stay in her home? Is this an option? I'm talking about someone you hire here....maybe a nearby nursing student or a trusted neighbor.