Trying to help..need insight

[SoggygranolaNurse]

I am a nurse liaison for a LTC facility.

I have recently been asked to screen a patient who needs rehab, ST, OT, PT. The goal is for her to strengthen enough to transfer to acute rehab. In order to do so, she must tolerate 3 hours of therapy a day. Based on my clinical assessment, this is not likely. The family is optimistic and supportive of her recovery and I don't think anyone has been forthcoming about her prognosis.

The issue with admission is, she has no payor source. She is community medicaid pending. She has assets, but I don't think they are prepared to do a spend down.

She has been screened by no less than 9 other facilities and has been refused for any number of reasons. Too heavy a care load, no female beds, etc.

I met with the case manager today and she is understandably frustrated that no one will accept the patient. That said, is it reasonable to expect a facility to take on a patient with rehab needs, who will also likely end up long term, with no payor source? I can't expect my administrator to be ok with losing $500 a day on her care.

I am trying really hard to help the situation but my hands are tied. Is it neglectful of me to be forthcoming with the case manager as to WHY there is a question of accepting her? Or should I have just said "no female beds"?

[CardioTrans, BSN, RN]

Maybe the case manager could get the insurance verification dept to try and find out what the status of her Medicaid is. Also, with what you are saying... she is going to need more care than an acute care rehab can/will provide. If she will "most likely wind up being LTC", most acute care rehabs wont take her. It "messes with the outcomes"....... (if I had a dime for everytime I have heard that).

Be honest with the CM... if 9 other facilities have declined her, the CM probably already has an idea of why.

[SoggygranolaNurse]

Thank you for your reply.

I suspect that the patient is a "dump". I am a new liaison for this facility and it doesn't have a very good history. We have a new management company that is doing some amazing things, but we can't seem to get out from under the medicaid and no payor source referrals.

I think the CM knows that she is going to be LTC, but it's also not practical for them to keep her there. I'm afraid it's the sad state of medicaid reimbursement right now. Even if she *had* Medicaid, our reimbursement rate is about $220/day. The Admission Director costed (is that even proper grammar?!) out her care to be at least $500/day following the current discharge plan.

We *can* provide what she needs and would love to be able to admit her if we can straighten out the whole financial mess. I told the CM that this is where we are and we aren't counting her out yet. Unless the family agrees to a spend down (the patient owns a home and two cars) she won't ever qualify for medicaid. Even with the 30 days of community Medicaid (with which we'd still be losing $300/day..I'd still take her to help out with referral partner relations) on day 31 we'd have NO payor source.

It's a mess and we just want to make sure all the "i"s are dotted and "t"s are crossed.

[CardioTrans, BSN, RN]

I so understand where you are coming from. The referral source has probably used your facility many times in the past with Mcaid pending patients, and the facility has agreed to accept them, so they may have come to expect "if no one else will take them X will".

Unfortunately, it usually takes 90 days for the Mcaid status to convert to active. So the patient is sitting in an acute setting, and not meeting criteria, but there is really nothing they can do other than eat the cost.

I have one right now, Medicaid pending...only on day 56. Needless to say, we cant move the patient anywhere until the Mcaid converts. I have an attending physician asking me everyday.. "what day is it?" He stopped me in the hall today and asked again. Think I am just going to give him a calendar with the days marked off on it. :)

[SoggygranolaNurse]

Thanks again. So is Medicaid retroactive?

I think with the assets there is no way she would qualify without a spend down. I don't think the facility wants to take the chance. Sadly, we would have to wait until she was approved before admitting her.

I understand the CMs frustration. They are full with a full ED, they need the beds to be cleared for new admissions.

*sigh* Hopefully it will all work out. I'm frustrated too that there is no place for these patients to go. People need care and it's shameful that their ability to pay is a motivator to their acceptance.

[edgwow]

Cardio Trans,

I had to laugh, how many times has that happened? They think that when we say day 56 we really mean day 89, they do not understand we don't make the rules, we just have to abide by them.. LOL

[edgwow]

In my large city, these pts get evaluated by the Corporation for Aging, medicaid applications are started and we wait until the actual application goes through. Many times , I have seen social workers send out over 50 referrals for facilities as far as 50 miles away, just to get them to see if they will ac cept the pt. That's a lot of faxes to send. We have had patients sit 6-7 monthes awaiting payor source and an accepting facility. Try doing this with an illegal, very ill immigrant. emergency medicaide due to hardship is possible but only good for 1 year.