My Mom fell and broke her hip and had surgery and was then sent to skilled nursing for rehab. She is 84 years old and in a great deal of pain. The Dr. has been working on adjusting her pain medicine. It addition to her hip injury she hurt her neck. She has only been there for less than 1 week and the PT is saying she is not making enough progress and Medicare will not pay unless she is making progress and she must be moved to a long term care facility.
Yet mom went to the PT session, rode the bike and did everything the PT asked. She is from another country and English is not her primary language and the PT has a hard time understanding her. Mom has a hard time to get up and the PT wants her to stand and move more each day, but she is in pain and very slow. I feel like they just don't give a Damn (sorry for the language, but their is no polite way to describe these people) and it is too much work and they just want her out.
What does the law state in situation like this? Can they kick out an 84 year old because the PT says she is not making enough progress? What are the real Medicare rules on making progress and paying for skilled nursing.
Any help in this area appreciated.
Her assisted living has no such requirement and in fact most the people there are in wheelchairs and can not walk on their own. Maybe you are thinking of independent living. The only requirement for her assisted living was the person could pivot for a 1 man lift and even that is waived after you are established.
"For Medicare to pay she had to follow their instructions and make progress"
I don't know why people continue to spread this false statement about making progress even after I showed the lawsuit and the settlement agreement. The main reason I respond to this inaccurate comment is for others can know the truth. The sad part is even the facilities don't know the truth about the Medicare rules.
I actually even talked to the lawyer that was involved in the lawsuit. As shown in the links I provided Medicare has come out and stated their is NO improvement requirement.
The Center of Medicare Advocacy filed a lawsuit regarding this specific matter in the case of Jimmo v. Sebelius. The outcome of that case is there is “No” Improvement Standard required for Medicare to cover skilled nursing and physical therapy. A doctor can order PT just for the patient to just maintain or not degrade.
I will include the links again. If people don't care about the actual facts, not sure what else I can say
Pub 100-02 Medicare Benefit Policy again stating the changes regarding Medicare Policy due to that lawsuit.
http://www.medicareadvocacy.org/wp-content/uploads/2018/08/Checklist.pdf
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R179BP.pdf
I’m not sure this is realistic. Think about this a moment ...I don’t think any surgeon will order this sequence. First is walking, then she will need to get up, stand and turn and then keep herself on the seat while flexing and extending her legs to ride a bike. Will she be able to do this? Of course in the beginning the staff will assist but at each continuing session they will look for your mother to take initiative on her own with the staff minimally assisting.
“What was her level of activity prior to surgery? “
There is a long history to explain so I will keep in brief. Mom walks with a walker but fell and was in outpatient rehab at assisted living. She had just gotten back to the point where she could walk with her walker again (short distances) when she fell and broke her hip in the elevator. So her walking ability was never great to begin with.”
Yet now her family are thinking she’ll do better the second time around? Past behavior is an indication of future behavior.
Maybe your expectations of your mother’s recovery are too high. It’s not easy to accept your patent needs more help and cannot care for herself even in a AL center. Goodness knows there are many of us here that didn’t want their parents in a NH (myself included) but nonetheless it happens.
All I am saying is you need a “Plan B” as currently she is not progressing. How is she going to the bathroom now? A bedside commode?
If she sits or lies down all day, she is going to develop bed sores, increase her chances of pneumonia, blood clots, etc
Maybe she’s just too tired to do therapy and doesn’t want to. That’s why thinking ahead is important- she may need a nursing home going forward.
Trust me, that Sebilius vs whoever case you cite isn’t going to save your mom from not being transferred to the SN side - a nursing home - if she can’t take a few steps now. You’ve clarified she had a rough time walking prior to this, her second fall.
What’s wrong with going to nursing home side and letting her progress at her own pace? Granted she may be self pay as Medicare won’t cover long term care.
Also, be realistic about her ability to remain at AL is she has already fallen twice and is generally immobile now. They don’t have the staff to monitor her when she is alone in her room. How is she going to get out of her room if there is a fire or evacuation like New Orleans with a hurricane?
There are exercises she do in bed as well but walking is first and foremost in any surgeon’s orders for PT. The surgeon may write the orders but the therapist carries them out, and if their post op hip protocol for physical therapy isn’t being met, they will be able to document “no improvement” & transfer her out to the SN side. And if you reach that point you have to have a back up plan.
I talked to a family member in another state who is an administrator at a large facility that does skilled nursing, nursing home, assisted living and the like and she said they care about their patients and never discharge a patient for the reasons we are being given so again it all is subjective.
In my opinion the therapy needs to be biased on the patients past history and ability. So if they cannot stand and take steps you have them ride the bike and do other exercises to build up strength so you can then take steps.
I would insist on a meeting with the PT, the financial department and an administrator to find out why they want to give Mom the bum’s rush.
Here are some websites that you can "Copy & Paste" to your browser about Medicare therapy.
https://www.medicare.gov/coverage/pt-and-ot-and-speech-language-pathology.html
https://medicare.com/coverage/does-medicare-cover-physical-therapy/ A non-government site powered by eHealth®
https://www.caring.com/medicare_information/medicare-coverage-of-physical-therapy
https://www.medicarehealthplans.com/news/does-medicare-cover-physical-therapy/
https://www.webpt.com/blog/post/medicare-part-a-vs-part-b-what-pts-ots-and-slps-need-to-know
I hope that you are able to communicate to the therapists that your Mother WANTS to do the therapy and exercises BUT that she is having difficulty because of the pain from the hip surgery and ?neck pain?.
I know my Dad's situation is different, because we are in Canada, but when he was in rehab after a major stroke, those who did well, worked hard all the time, not just in the PT sessions.
Most if not all the patients are in pain and have to learn that they will not get better if they do not push through the pain to do their exercises. Now everyone has a different pain threshold, but they still need to understand that PT cannot wait until there is no more pain.
Dad is 3 years past his stroke and does remarkably well, but still has to do his exercises daily. He has a set he does in bed before getting up, he alternates a 1 km walk with stair climbing and he lifts free weights, daily. He also has hand exercises he does throughout the day Yes, Dad is very tired by early afternoon, so he makes sure he does his main exercise before lunch time.
Perhaps your sister can make an appointment to ask what exercises Mum can do on her own or she can do with Mum in additional to the PT sessions. She can also do up a few cards in your Mother's first language with the various instructions the PT needs to be able to give, as well as a set of answers in English and Mum's language, so she can reply.
If you call, or your sister can ask, what are the goals of the PT sessions? How much recovery is Mum capable of and what will she need to do to get there?
It is unfortunate about the afternoon sessions, hopefully some are in the morning too. It is the nature of a rehab facility that not everyone can be seen in the morning.
There is so much information about music being added to PT. Perhaps see if your sister can find some recordings of the music your mother loved when she was younger to play during sessions. An upbeat song may encourage her to move.
I think everyone is genetically different. There are folks over 100 that play golf. You are lucky that your father is in such great shape that he can work out with weights, but not every person in their 80s are so fortunate. I think mom is doing the best she can. Prior to this she was in assisted living and did their daily exercise, but she is not in great health and shape. Yes she could have done more to stay in shape and work out when she was younger, but that is history. She has had back injuries and other issues in the past.
I just think the whole Medicare skilled nursing system is a disgrace. You are fighting with 2 large bureaucracy and no one advocates for the patient. Instead of having a doctor that knows your history you are under some Doctor paid for and hired by skilled nursing making decisions for you, that can not even spend 5 minutes talking to siblings. I cannot imagine how one could device a worse system.
It is very difficult as I live in another state and was just in Memphis and cannot go back immediately. My sister lives there but does not seem to like confrontation as I ask her to do just that.
My sister watched her and the PT and she told me the PT has problems communicating with my mom and that she wanted her to do a full hour and mom was tired after 30 minutes. And that she wanted her to get up, but mom was in pain but could still get up.
This is the problem I have no idea what not making enough progress means. It is completely arbitrary IMHO.
And I am not sure what to do next.
I did start to look online and see that there have been lawsuit that were won regarding reaching a plateau.
Different thing happen on different days, but my sister went there yesterday and watched PT. My sister said they did not come until afternoon so my mom was already tired.
My mom is not refusing to do therapy. She did 15 minutes on the bike and she was very tired from it being late in the day and after doing the bike for 15 minutes. So she was both wore out and in pain.
The PT then wanted her to stand up and take a step. Mom was able to stand up very slowly but could not take a step due to being worn out and in pain. So they ended the PT session for that day.
And according to the PT that is not enough progress.
Frankly to me that is complete, you know what. But I have no idea what the Medicare rules are in situations like this. I wish there was some lawsuit I could reference or something.
Communication is extremely important when a loved one is doing therapy. Please do not get upset and angry (or confrontational) when you or your sister are talking to the therapy staff. It will only make things worse. Be respectful but firm.
Contact the physical therapists at the facility and explain the situation to them. Ask them to explain the guidelines that they must follow for your Mother to continue to qualify for Medicare. I know from experience that the guidelines are very complicated and sometimes difficult to understand or to apply properly to the resident. In regards to standing and walking the resident needs to increase the number of steps that she/he takes each day that they have therapy otherwise they might not be considered as "progressing". Since your Mother has only taken one (1) step and has not progressed to taking more than that, then Medicare can consider her as "not progressing" and terminate therapy.
Many "Skilled Nursing Care" facilities are also "Long Term Care" facilities. When Medicare coverage ends, the resident moves from the "Medicare Unit" to a "Long Term Care Unit". Is your Mother in a "Skilled Nursing Care ONLY" facility that has no other nursing care units or floors where long term residents live? If your Mother has to move to another long term care facility, make sure that it is one that offers Medicare Physical and Occupational Therapy within that building. It may be that your Mother's hip needs more time to heal before physical therapy can be done. Once Medicare ends, will your Mother be "private pay" or "Medicaid"? Either way, your Mother can restart Medicare-paid Physical Therapy or Occupational Therapy when she is stronger and the pain is under control.
Is your Mother having Occupational Therapy during the morning? If so, ask if Physical Therapy can be done in the morning and Occupational Therapy in the afternoon. Ask the nursing staff to lay your Mother down in bed after lunch so that she is not so worn out for any therapy in the afternoon.
You have stated that your Mother is in pain when she stands up and takes a step. Does your Mother use a wheel chair most of the time or does she walk to and from therapy OR to and from her room to the dining room? If she has a wheel chair, has it been designed for her or is it one that the facility owns? When your Mother stands up, does she use a walker--is the walker the proper height for her or is it too short or too tall? Where is the pain when she stands up and when she attempts to walk--in her hip? in her knee? in her low back? Does your Mother have the same complaint when nursing staff assist her to transfer from wheel chair to bed or to toilet. Or does the nursing staff use a "Sit-Stand" (or "Easy-Lift") mechanical transfer device with your Mother for transfers in her room? Can your Mother stand, take a step or stand and pivot from bed to wheel chair in her room with assistance of nursing staff? When are her pain medications scheduled? Ideally, pain medications are given 30-45 minutes PRIOR to therapy sessions so that the maximum amount of pain medication is in the blood stream.
Ask if the doctor can order a hip x-ray (while standing) to see if your Mother's hip is healing or to see if there might be a physical cause for her pain when standing.
Continue to ask questions and attempt to work WITH the therapists to resolve the problems that your Mother is having with therapy. I know that it can be frustrating when someone does not do what you expect them to do, whether it is a therapist, a nursing staff member, a resident or a family member.
Have you had a chance to review any of the websites that I listed for you in another posting? I think that they might answer some of your questions.