According to the Centers for Disease Control and Prevention (CDC), an older adult falls every second of every day in the US.Last month, my mom joined the ranks, suffering multiple fractures from a fall in my home. As I continued my role as her primary Care Partner, I also became her primary Caregiver.
Mom is making tremendous progress and, fortunately, all the professionals in her life believe she will walk independently again. For that I am grateful. However, I now understand, firsthand, the tremendous toll that a fall like this can take on a family. Today, I share some ideas regarding things you can do if you find yourself in similar circumstances.
How Medicare/Insurance works
For Medicare/insurance to pay for an individual to receive care in a skilled nursing facility (SNF: inpatient care utilized after a hospital stay, following an accident, severe illness, or surgery), certain conditions must be met. The goal is to help the person regain their ability to do “activities of daily living” such as bathing, dressing, cooking, personal hygiene, walking, and getting into/out of a bed or chair.
The determination of whether an individual continuously meets the criteria for payment in a SNF is scrutinized by insurance-based personnel. They rely on documentation provided by onsite physical and occupational therapists, who outline the objective and quantifiable physical goals an individual must work towards and meet. Upon admission to a SNF, and based on an algorithm, a discharge date is projected and immediately communicated to the family.
In this situation, our clients frequently experience two powerful emotions: fear, followed by anger. I felt both of these!
In my case, the fear came from wondering how I could possibly care for my mother at home by the date that was communicated. The anger came from being forced to worry about mom’s impending discharge at the same time as I was worried about her immediate injuries and what lies ahead for her and for my dad.
Just when I needed reassurance that things would be okay, it felt like I was being threatened that care would be taken away. I know “threatened” is a harsh word, but I felt it.
First, I was told that she did not qualify for hospitalization beyond the emergency department visit and that she had to leave within 24 hours. Then I was told the SNF stay would be short, because she was non-weight bearing. She would therefore fail to qualify for continued aggressive physical and occupational therapy until she could put weight on her foot and arm (that was 12 weeks away).
Once home and receiving home-based care, the projected discharge date from that level of care to outpatient physical therapy (to which she needs to be transported regularly) was quickly communicated.
Overall, and despite my vast knowledge and experience managing all of this with our clients as well as my deep understanding of how Medicare/insurance functions, it still felt awful. It felt like the healthcare/insurance systems were not supporting us as a family the way we needed to be supported.
Take Charge of the Situation
When someone has a traumatic fall that results in a hospitalization, a stay at a SNF, and an eventual transition home, it’s critical that someone in the family take charge. There is so much to quickly manage and learn.
I understood how important it was for mom’s first transition to be to a SNF that was of high quality, so finding that became my first and highest priority. That decision set the tone for her recovery, and I am grateful to have found a SNF team that communicated with transparency and that worked in partnership with us to achieve the outlined goals.
But make no mistake… this took me away from everything else in my life (to those clients for whom I have been less responsive, thank you for understanding). Compromises had to be made to attend to the immediate matter and I had to be the one to step up.
If you have siblings or others with whom you can share responsibilities, make it known immediately that you need help and assign tasks. I am so grateful that in our situation, my dad, Anthony, and my husband, Bob, were on mom’s team. Working together made it all just a little bit easier.
Challenge the Jargon
When you are dealing with health care professionals, whether in a hospital, a SNF, or with therapists providing care in the home, the professional language they use can sound very foreign.
“Max assist,” “contact guard,” “instrumental activities of daily living,” “core muscles, “motor planning,” “proprioception,” etc., etc. This terminology is used to describe an individual’s abilities, the goals they are working toward, and how progress is being measured.
But what do the words actually mean? To a lay person, such language is ineffective at communicating what your loved one’s needs will be when they return home to you.
So, when meeting with these professionals, ask for explanations. Here is some of what we asked…
- What are the measurable and quantifiable goals mom is working towards?
- What can she do alone and what does she need help with?
- What kind of help does she need to get out of bed? Can I do it alone or will she need the assistance of two people?
- What equipment can be used to help her?
- Can I attend your therapy sessions with mom so I can observe and learn?
- Can you provide training to me and my dad?
- Can we practice what needs to be done so you can provide tips and help us develop solutions to problems we may encounter when she is in our home environment?
- Can you come to our home to do a home-based assessment so you can see what the layout is and offer suggestions?
- How do I get over my fear of bringing her home?
For the first two weeks mom was home, dad and I worked together to perform every change in position while she was in bed and to manage every transition into and out of her wheelchair. With a broken shoulder and broken foot, mom could do very little for herself and yet, because the therapists stated that she could transfer with the assistance of just one person, she was ineligible to stay in the SNF for any longer.
What I realized after those two weeks is that I could have done some things alone, as the therapists did. But I was dealing with incredible fear that I would drop her, causing greater injury. If you find yourself in this situation, make the best use of the experience of every professional you encounter along the way. Ask them to not only teach you but to practice with you.
Everything gradually improved, but in the meantime, there was a lot of sleep lost and quite a few tears.
Know Your Rights; Push Back as Needed
If your loved one is receiving care from a hospital, SNF, Hospice, or from a Home Health Agency and you are told that Medicare/insurance will no longer pay for care, you have the right to an expedited appeal. There are separate processes, depending on the type of facility and the type of insurance. There are also different levels of appeal if you are unsuccessful with the expedited one.
Overall, determinations will be made based on the quality of documentation provided by the medical personnel, along with other factors. So, educate yourself beforehand about this topic, in case you need to take action.
In our case, and without a formal appeal process, I was successful at negotiating four additional days in the SNF as well as an insurance-covered ambulance ride to see a specialist about a complication mom was experiencing. The outcome of that visit had a life-changing result, allowing mom to resume normal bodily functions.
I believe that the open communication and the relationships I developed with everyone in the SNF, the insurance case manager, and the specialist’s team of professionals along the way, helped to make it all happen. But that is not always enough, so be sure to know your rights.
Final Thoughts
A phrase that has become common in our household as we continue to progress through this experience is, “It’s all about the pee, the poop, and the pants!” Managing this intimate function of getting pants up and down still causes us to break out in laughter, because invariably, I forget one of the multiple steps in the process.
Being able to laugh loudly and often has helped us so much and is a reflection of the precious relationship I enjoy with my parents. I hope you never have this experience, but if you do, I hope you can find laughter, too!