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Our father is in rehab. They have said they will discharge him to Hospice due to having plateaued or not improving with therapy. Family and father wants to continue rehab. Can the center discharge him without approval from an immediate family member? Wife, son, daughter? We are in the commonwealth of Virginia.

Medicare will not cover a patient who cannot improve with further therapy. That requires transfer. Whether transfer is to home, to nursing facility is not a concern for them. They will be discharging the patient to somewhere or the patient will be "self-pay" once that plateau has been reached. Hospice is generally not used without the knowledge of patient and or family (if patient is unable to decide) as hospice requires MD agreement that in all likelihood the patient has no more than six months to live. The patient, your father, currently in rehab does have an MD assigned. Speak to this MD. Social worker at the facility also can inform you, and will likely be easier to reach. Make an appointment with the facility Social Worker today.
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needtowashhair Dec 23, 2019
"Medicare will not cover a patient who cannot improve with further therapy."

This is completely false. Nothing further could be from the truth. This is a falsehood perpetuate by the for profit health care industry.

The real criteria is to slow further deterioration. Not to improve. Not to hold steady. But to lessen the degree of loss of function.

Here it is directly from the horse's mouth.

In plain English on the CMS website, they run Medicare.

"Such a maintenance program to maintain the patient's current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program. "

https://www.cms.gov/Center/Special-Topic/Jimmo-Center

From chapter 8 of the Medicare Benefits Manual. The chapter that governs SNF. I capitalized the relevant words.

"Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or SLOW FURTHER DETERIORATION of the patient’s condition."

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08pdf.pdf

Don't make me reference the U.S.C. that governs all this.

"No improvement" has never been the criteria. I don't know how it became a thing in the for profit health care industry.

Just so it's clear, it's not that Medicare won't pay. The facility is just afraid they won't. So when you get that discharge notice, fight it. The first best chance to win an appeal is the third one. The first two are done by another health care provider. That third one is with a judge or a Medicare employee. At the third one, you should be appealing to someone who knows the real policy and law.
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Just because a person is not progressing in rehab does not mean they qualify for Hospice.
If your father qualifies for Hospice that means there is probably no chance for him to improve, no chance that he will "get better" more than likely he will decline and the decline will continue.
You do not have to accept Hospice. If a person wishes to continue treatment then they are not Hospice candidates.
Hospice is a WONDERFUL option when there is no chance, no hope for improvement.
The support both for the patient and the family is amazing.
Hospice will care for your dad, they will not "kill" him with over doses of medication. They will make it their goal to make sure he is not in pain.
They will educate you, the family what is next.
But again you do not have to accept Hospice. You can have him seen by his primary doctor.
The rehab facility will discharge him to where ever he was residing previously to the rehab stay. If that was an Assisted Living facility he may not be able to return if he needs more care than they can handle. If that is the case he may have to be discharged to a Long Term Care facility or Skilled Nursing facility. The discharge staff can help with that.

When you are ready, when the family is ready please consider Hospice to help you all through this difficult journey.
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Reply to Grandma1954
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As said, Medicare determines when rehab stops based on info provided by the Therapist. It means that therapy cannot help Dad further. He is as far as he can go.

Be aware that if Hospice is done at a LTC facility that the room is private pay. Hospice provides a Nurse, an aide, supplies and medication. Dad will be taken off any lifesaving medication. He will only be kept on comfort/pain meds. (If diabetic these will be continued but dialysis won't be) If done in the home, someone has to be with him 24/7. The doctor will give Hospice an order for care. A Nurse will come in to evaluate and if the need is there, she/he will admit Dad. A Nurse and aide will only come about 3x a week. Family will be responsible for the rest. So if Dad can afford Hospice in a facility, u may want to go that way. When the Hospice staff is not there, the facility staff takes over. You should be able to contact the nurse 24/7. Make sure you understand how Hospice works. We have had members feel their loved one was overdosed. That LOs wishes were not taken in consideration. Ex: that patient said he didn't want a pain killer because he didn't need it and it made him sleep. The nurse gave it to him anyway. If LO can decide for themselves than the nurse needs to abide by it. Some don't care for the Hospice Agency being used. You can change agencies. Just make sure u understand the process. The Nurse s/b available to answer any questions u have. There is someone above the nurse if u have a problem. My experience with Hospice has been good in my area. I just think sometimes its a lack of communication. Remember that there is a lot of stress for the one closest to the patient. That person does not always hear or interrupt well. I used to have to re-explain things to my Mom that was said. "No Mom, thats not not what was said". It only takes missing one word to change the whole sentence.
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needtowashhair Dec 23, 2019
"As said, Medicare determines when rehab stops based on info provided by the Therapist. It means that therapy cannot help Dad further. He is as far as he can go."

This is completely wrong. Not improving is not a reason for discharge as far as Medicare is concerned. Look at my response to AlvaDeer for proof of the real policy.
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What placed dad in rehab? Is it a terminal condition?
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Either ask or do some research on this particular rehab facility.  If it's part of a joint venture, or broader entity (such as an LLC) that ALSO has a hospice facility, then you have your answer:   $$$$$.

Over the years I've seen more expansion of medically owned LLCs, providing a range and step-up of care.    And from another angle, I've seen some venture capitalists involved.    Big bucks involved, and the VC's want returns on their investments.  

Capturing clients and keeping them in the larger medical chains is I think a way to get those desirable big fat ROIs.


You've gotten very good advice.     The decision to go from rehab to hospice seems to be a radical, drastic one, unless there's more to the situation than we know.    That did happen with my father; he was nearing the end of life and just couldn't complete rehab, but I had already done hospice research and made decisions so it was a matter of segueing from rehab to hospice.   

But do get not only the facility's doctor's opinion as well as your own physician's, perhaps the one who scripted for rehab.

It might also be helpful here to share what his medical conditions are to create perspective on the severity of his situation. 

However, remember that (to the best of my knowledge) the facility can't consent to hospice on his behalf unless they take legal action and get control of his life.    Make sure that doesn't happen.  


And slightly off topic, but a caution:   I've just been through a situation in which medical records are "supposed" to be entered online, through a portal created by a venture capital firm which requires the patient to indemnify, hold harmless and defend the VC firm.   DON'T ever agree to this.   I doubt if there's anyone here on this forum who could afford to defend a VC firm for ANY of its decisions or actions.    It's a bankrupting concept.

I did some more research and learned that the VC firm focuses on the medical field, including "capturing" relevant data to "help" improve the patient's "decision making and choices".   What it wants to improve is its own bottom line.
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sanhoro12 Dec 22, 2019
There needs to be some medical information in the original post as to why he's in rehab and how this affects his life expectancy. There is a lot left out of the post. The rehab facility will involve the family in the discharge planning and vet the home situation for whether palliative care can be administered there.

There is a vested interest with hospitals and hospice to move patients into hospice to avoid readmits for which they are penalized by Medicare. There are also financial fees for referrals for hospital to hospice. There is a local hospice here where their employees' motto is "Get them in, Get them out."
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If your father has reached a plateau and doesn’t want to leave then you need to look in to getting him moved to long term care. And no the rehab doesn’t need approval from an immediate family member unless your father is incompetent and unable to make his own decisions.
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Reply to worriedinCali
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When my dad was in rehab and plateaued, a care conference was called with all providers of care an me in attendance. The case about my dad was presented and my questions answered. It was decided that AL would not take him back and he had to go to LTC. I can’t imagine any facility making a decision to add hospice without speaking with you first for consent if you have MPOA. What is his diagnosis that he requires hospice. We’re you consulted in a case conference? If not you have a right to it.
medicare won’t pay for rehab if he’s plateaued, but you do have a right to appeal. Where did he live before going to the SNF rehab facility?
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rovana Dec 22, 2019
If the elder is competent, then I don't think family calls the shots re hospice.
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You can appeal a cut to therapy within 48 hours of the cut. Hospice sign on requires consents to be signed. If your dad is able to make his own decisions he will decide and give consent. If he can’t and someone is POA tgen that person signs consents. A nursing/rehab facility cannot just sign him on. If you lose the appeal you have the option to private pay for therapy but if he’s not making progress they won’t want to continue because it isn’t helping. It may mean there is a new normal in tge level he is at. I don’t know your financial situation, but you have the option to take him home, you can look into AL (which is private pay) or a nursing facility. There are all kinds of options. An area office on aging can answer questions if the rehab SW isn’t helping
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needtowashhair Dec 23, 2019
There is no improvement criteria for Medicare. The bottomline criteria is to "slow further deterioration". Look at my response to AlvaDeer for links to the real policy.
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This looks as if the rehab facility is saying "because your father isn't improving (i.e., has "plateaued"), he probably has only six months or so to live. However, it seems there would be a LOT of room between responding to therapy and being ready for hospice. It DOES seem strange that hospice is the solution they've chosen (although our not being there makes it impossible to know all the circumstances). As others have suggested, nursing/long-term care would appear to be a possibility.

During my father's last year of life, when he was in a nursing home, physical therapy was attempted, but the therapists finally said "he is simply incapable of doing anything" so it was terminated.
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worriedinCali Dec 22, 2019
Actually depending on dads health, going from a failed rehab attempt to hospice isn’t strange at all. It’s exactly what happened with my FIL. He made no improvements in rehab, was sent back to the hospital because there was no plan of action & rehab couldn’t keep him if medi-cal wasn’t going to pay the bill (and they weren’t). Rehab made a lie that he had a UTI & sent him back to the hospital. Hospital said there’s nothing we can do for him, he’s not going to improve and he then went in to LTC on hospice. Died within 2 months. It’s not at all uncommon or strange.
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Yes, Medicare (and other insurance companies) sets the rules. Medicare does not need "approval" of the patient or the family.
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humes11 Dec 22, 2019
Yes, I do agree. Medicare sets the rules. But you can disagree with Medicare and sign. I disagreed with discharge under Medicare law. It is important to communicate with Medicare on denials. We have rights under the Federal Government. Let me know what you think. PA resident.
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