The phone rang early one Tuesday morning. It was a client, Richard; his father was scheduled to be discharged from the hospital to a skilled nursing facility in two days.
“You’ve got to be kidding me,” he said. “My dad’s team says he’s ready to be transferred but I don’t agree. They gave me a list of Medicare-approved skilled nursing facilities to choose from, but I have absolutely no idea where he should go. I’m lost and I’m angry. I want to do the right thing for my dad so where do I start?”
The crisis Richard was facing began a few weeks earlier with an emergency hospitalization for his father, David, who had fallen at home and was hospitalized for surgery of a fractured right hip. David’s situation was complicated by his underlying diabetes and a change in his cognitive functioning thanks to anesthesia and pain medications.
Now it was time for his transition from an acute hospital setting to a skilled nursing facility (SNF) setting. For many older adults, this kind of transition is when common misconceptions about Medicare become obvious.
Misconception #1: “The doctor decides when I leave the hospital.”
Richard had only recently met the surgeon who performed the operation. When the physician said, “our team will take good care of your dad,” Richard assumed that meant that the physician would make the final decision about when his dad would leave.
The reality is that although your provider certainly weighs in on when you should be discharged, members of the extended hospital team and your level of insurance coverage influence that decision.
The case manager/discharge planner works with the team to plan for discharge and is monitoring to be sure that the criteria Medicare sets for someone to be in an acute care hospital are being met. If they are not, the hospital runs the risk of Medicare not paying for additional hospitalized days.
As a rule:
- The hospitalized individual’s condition must be such that the care required can only be provided in an acute care hospital, or he/she required a SNF level of care but no SNF bed was available.
- Even if an individual has Medicare supplemental coverage, if Medicare doesn’t cover the expense, neither will the supplemental insurance provider.
To “manage the reality” and not find yourself surprised, here’s what you can do:
- Plan for discharge as soon as you or a loved one is admitted to a hospital. (You’ll notice that “planning for discharge” is first on our list in all three scenarios described today!)
- Immediately establish a relationship with the physician and case manager to obtain up-to-date information about the plan of care, the goals and expectations of each day, and when discharge is anticipated. The team is thinking about it up front, so they should share that information with you.
- If the need for a transition to a SNF is likely, immediately discuss potential facilities with the case manager and the physician to obtain their opinions based on the care that will be needed and their previous experience with that facility.
Begin your own research by doing the following:
- Identify at least five facilities to investigate as bed availability on the day of discharge changes constantly.
- Read about the facility online.
- Check your state web site to review the facility’s quality, safety and oversight, certification and compliance status.
- Call the facility, ask for the admission’s coordinator and schedule a meeting including a tour of the facility.
- Begin to establish a set of criteria by which you can evaluate each facility, specific to your particular situation. This may include accessibility and quality of medical oversight; quality of the rehabilitation team (are they employees or contracted staff?); distance from family members; the availability of a private room; etc.
Misconception #2: “Medicare will cover my stay in a skilled nursing facility for up to 100 days.”
The reality is that Medicare does not automatically cover 100 days. Rather, it will cover skilled nursing care provided in a SNF under certain conditions, for a limited time. Here are some things that need to happen:
- A physician must order the services that require the skills of professional personnel like registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech language pathologists, or audiologists.
- You get the required skilled care on a daily basis and the services must be ones that can only be provided in a SNF on an inpatient basis.
- You continue to make progress toward an outlined plan of care that includes objective and measurable goals.
As a rule:
- For days 1–20 of your stay during the benefit period, you don’t pay anything. For days 21–100, you pay a co-insurance as determined by Medicare or your secondary insurance. Beyond 100 days, there is no benefit coverage.
- Initial evaluations by the professional team, an outlined plan of care that includes objective and measurable goals and a potential discharge date are completed within 72 hours of the admission.
- Progress toward an outlined plan of care that includes objective and measurable goals is re-assessed weekly (more often in certain circumstances).
Note: “Short-term rehabilitation” is a term synonymous with SNF.
To “manage the reality” and not find yourself surprised, here’s what you can do:
- Plan for discharge as soon as you or a loved one is admitted to a skilled nursing facility.
- If possible, be present and participate in the initial evaluations conducted by the team of professional personnel so that you can represent the baseline level of functional ability your loved one had before hospitalization.
- Participate in the process of setting the objective and measurable goals being outlined so that you fully understand how your loved one will be re-evaluated for continued stay in the facility.
- Request a team meeting soon after goals are outlined and request communication about progress. Remember, the team must re-assess weekly and is reassessing continuously as care is delivered so that information should be readily shared.
Misconception #3: “Medicare will pay for my stay at a long-term care facility (LTC) / ‘traditional’ nursing home.”
The reality is that Medicare does not pay for long-term care in a long-term care facility/nursing home.
As a rule:
- If your loved one is in a SNF and has stopped making physical progress toward objective and measurable goals, but they need help with activities of daily living (ADLs), and there is no one to assist at home, they are determined to need “Custodial care.” Custodial care is not paid for by Medicare.
To “manage the reality” and not find yourself surprised, here’s what you can do:
- Plan for discharge as soon as you or a loved one is admitted to a skilled nursing facility.
- Early on, consider the option that your loved one may not be able to return home.
- Assess your financial situation and talk with your family, financial planner or estate and/or elder care attorney about how you might pay for this.
Conclusion
Unfortunately, a crisis like Richard and his family experienced is not uncommon. That said, with good information and the patience to sort through and understand the details of what Medicare coverage entails, you can stay informed and be a leader in your own healthcare or that of a loved one.