Saturday, June 23, 2012

A Map through the Medicare Maze

Recently, my father had a stroke. From the hospital, he went to a rehab center and, having made no further progress for some time, has to leave or pay full freight for his continued stay there. He can't go home: he can't take care of himself and my mother can't take care of him (she's in a wheelchair), and they can't afford round-the-clock care. The nursing home staff didn't have any helpful hints.

However, Deb Flentje, whom I buy pasture-raised meat and eggs from, was kind enough to take the time and effort to write out a map through the Medicare maze. Deb used to work in the nursing home field, in a management capacity, as I recall. Here's her description of how Medicare works, and how to choose a nursing home for a loved one.


 Medicare and What it Covers

First ask for a meeting with the social worker in the hospital. Ask for that person to explain what Part A Medicare and Part B Medicare covers in the nursing facility and assisted living facility and home. Then ask which facilities she recommends for the best rehabilitation. Ask her if those facilities have an Admissions Coordinator that comes to the hospital to evaluate the patients, answer the patient's/family's questions, and will coordinate the transition to the facility. Part A Medicare will cover all costs of his Part A stay. The length of coverage is determined by the initial evaluation done by the nursing facility team and the completion and submission of the MDS form. Your Dad's progress also will determine how many days are covered. Keep close tabs on this, as once he is discharged from Part A, he must be either transferred home, to an assisted living facility or to a private pay bed in the facility. The only expenses covered by Medicare in the nursing facility after coming off of Part A are PT, OT, and Speech therapy treatments, covered under Part B at 80% Medicare and 20% co-insurance, dependent what your plan covers. If he is transferred to assisted living or home, Part A Medicare can cover Home Health services through a Medicare Certified Home Health Agency. Medicare will cover his nursing and therapies at 100% as long as he is making significant progress,  he requires the skills of the nurse and/or the therapist, and he is home bound. This will most likely be short term.

 Getting Recommendations for a Nursing Home

Also, talk with your personal physician and your Mom and Dad's physician to see which nursing homes they would recommend. Ask if your Dad's doctor will come to the nursing home to supervise his care there. Most doctors now do not go to nursing homes, with the exception of those who specialize in nursing facility care and that is all they do. You will most likely have to ask the nursing facility for recommendations on which doctors that serve their facility. Ask how many hours per week each physician is in the building. You want a physician that is there and accessible on a consistent basis. Another suggestion is to ask your friends and co-workers if they have any experience with nursing facilities and physicians around Denver. You will begin to hear some facility and physician names that keep coming up. These are the ones to check out personally with a scheduled tour.

 Inspecting the Nursing Home

On the tour, observe the patients and staff. Are the patients happy, content, engaged in life, well positioned in their wheel chairs, clean and neat and dressed appropriately. Are the staff happy, interacting with and concerned with the patients' needs, helpful, courteous, friendly. Is the facility attractive, inviting, clean, and well cared for. Is there an easy means to get outside and sit outside?

Ask to see the dining room and see if it is attractive, inviting, clean, happy, and staffed. See what the menu looks like. Are there choices the patients can make about their meals? Is the food attractive and good tasting. I would ask for a sample. Food is so very important. Are there plenty of staff to help the patients and do you see help given.

Ask to see the therapy room(s). Is it a busy place with lots of patients working with therapists. Do they seem to be working hard and working well with the therapists. Ask them to describe their therapy staff. PT, PT Assistants, OT, OT Assistants, and Speech/Language pathologists. How many of each, How  many hours are they on the premises, how long have they been coming to the facility, who is the leader/manager, are they on staff or coming from a contract therapy company. How many patients are on Part A therapies now? How many are on Part B now? How many are on Hospice? What percentage of patients are discharged home or to Assisted Living?

Ask if the therapy team positions the patients in their beds and wheel chairs using pressure reducing mattresses, seat cushions, and other positioning devices to promote good posture, function and mobility, comfort for the patient, and to prevent pressure ulcer development. Ask them to describe their pressure ulcer prevention protocol and their protocol when a pressure ulcer develops.

Being an Advocate

This is super important to be aware of and to state to the nursing facility staff that you talk with. You must state up front that you are interested in your Dad getting a shot at regaining his independence to return home or to be as independent as he can be in whatever setting is appropriate for him. Unfortunately, there is a movement in health care today for physicians to make assumptions and decisions about a person's  quality of life, potential, worthwhileness that then determine if they "deserve" rehabilitation or should just be put on hospice and have their death brought about  prematurely by not providing things like antibiotics, hospitalizations, therapies, etc. Tell them what your Dad was like before the stroke and that you are expecting him to be given a good chance at rehabilitation to really explore how far he can come back to wholeness and independence. I have literally seen hospice staff trolling around a facility looking for admissions. Hospice should be for true END of life situations where death is eminent.


tess said...

thank you for sharing this information with your readers -- it's bound to be invaluable when people have a sudden need. they're surely upheaved emotionally, and have to make informed decisions in a timely fashion ... i can only imagine how hard that is.

best wishes to you and your family, Lori!

Lori Miller said...

Thanks, Tess. I couldn't find this information on the web, and thought it might be helpful to others.