Can rehab facility discharge to Hospice without consent from spouse/son/daughter?

Wandervogel, you don't say how long your father has been in rehab, but Medicare pays for therapy for a maximum of 100 days. However, if the assessment of the physician and therapist is that further therapy will not "prevent or slow further deterioration" (for example the patient continues to deteriorate even with therapy) or the patient is not willing/able to participate in therapy, Medicare can deny coverage.

Please talk with your father's care team, and ask for a Palliative Care consult if you haven't had one already. They can help you understand why hospice is being recommended. As others have said, just because your father doesn't qualify for rehab therapy doesn't automatically mean he needs hospice. There needs to be a medical condition that predicts six months or less life expectancy. But, if he does qualify, hospice can provide an additional layer of support to make his last weeks or months as comfortable as possible.

It can be difficult wrap your head around going from a rehab focus to an end of life one. Ask questions of the health care team until you feel you fully understand why the change has occurred. My best wishes to you as you navigate this. Your father is so fortunate to have the support of his caring family.

NO they can not! Hospice is a decision which has to be made by the individual or family! Only the individual can admit someone into Hospice!!!

Based upon my experience, they cannot force hospice on you unless the HPOA, or the parent if capable of decision making, agrees to it. They can send him home. Perhaps they feel he will not get care at home? Medicare will only pay if you can do physical therapy, so our choice was to either try to stick it out with no home care ( since parents were not on Medicaid) or agree to let hospice come in. They made a point to tell us that it did not necessarily mean only 6 months to live, but that the person would not be getting better and was not expected to live for more than six months. My mom was in a rehab nursing facility and we made the decision to take her out. When she got home, she immediately started doing the very exercises she would not do at the facility - so you never know.

My response only covered the discharge from rehab, which often will happen when someone has plateaued or is not making improvements - this is because Medicare will refuse to pay any further. That, as I noted, is something he and you will have to work with staff and Medicare for appeal.

As for hospice, I am sure they can recommend it, but there is nothing that says you have to accept hospice. Usually it is a primary care who recommends it, but you don't have to take it. Where was he living before, at home or AL? What needs does he have and is it something that you all can work with him on? Can he afford to hire his own therapy? If he was in AL, would they accept him back in his current condition?

There are too many questions which make it difficult for any of us to answer or make good suggestions. If you can/will provide more information, perhaps someone would have ideas for you.

I fthey Feel Hospice is Best right Now, You need to Prepare. Hospice will only take them if 6 months to Live so they must Know Something.....Talk to Them. Or you can Bring Dad home.

No experience for me with hospice or rehab, but PT ordered for mom living in MC was refused by her (they tried various ways to get her to work with them, but she can be very pig-headed!) After several refusals, she was "discharged" (I found it funny that the reason given on the paperwork was "goals met") Once this is reported, Medicare won't cover the cost.

In OP's instance, there is no indication of why he is in rehab or what reasons might have been given for discharge. Medicare will often refuse to pay if someone is not making "progress." What their definition of progress is could be different in various scenarios. You need to find out what he was receiving for care and why they think he isn't improving and then determine if you can fight/appeal. It also isn't clear (mainly because we don't know what his condition is) why hospice was suggested.

If one feels a LO can benefit from extra care/PT/OT/rehab, one can choose to bring LO home and pay for that care if Medicare denies it even after appeal. Also not determined is who would be the decision maker - aka is dad competent and if not does someone in the family have DPOA/MPOA? The best OP can do is find out all the details and what recourse there is. Without details, there really isn't much we can provide.

Rehab facility said my mother was "too well to stay there." WRONG ANSWER! Dead wrong as less than 48 hours later she suffered a stroke there and she did not live.

Seems like they are trying to find another way to pay for your dad's care. Rehab is for people that can be rehabilitated. If he does not make progress in an expected amount of time (see what your state and county definition of that is) then they can no longer "bill" the insurance company for rehab. If he is expected to die within a specified period of time (again see what your state and county definition of that is), then his care can be billed and paid for by insurance as hospice. Rehab can discharge him is he doesn't meet the criteria for rehab. Hospice is comfort care treatment that can be done at home or in a residential facility. A doctor must write a prescription for hospice. I suggest you have a talk with the social worker and/or administration personnel at his facility to better understand their process. It seems they want to keep him as a client as well.

It's possible that they did a hospice waiver, and he is being treated under hospice care at the rehab facility. They need the signatures of the facility's doctor and the hospice doctor.

Short answer is yes they can dismiss your father from rehab. They check his home to be sure it is safe. He will either go home and hospice will come to check on him or if he only has a couple of weeks left, he can go to a hospice house. BUT, you need to speak with your Dad’s doctor for a reasonable prognosis before you do anything.

You are so right about the medical records. I believe HIPPA laws were created to protect the Doctors, not the patients. They are using scribes with doctors to keep records of visits. Editing medical records are under interpretation and this is a game of ethics.

I am not a lawyer, but the decision to put a person on hospice must be by family.

My father fell and broke his hip in April. Had surgery went to rehab and the hip healed however they found he was in renal failure and he passed away Sept 1. Medicare only covers I believe 100 days per year for a facility and the doctor has to see improvement in the patient or Medicare won’t continue to pay for rehab. We brought dad home, hired a physical therapist to come to the home to do PT but Medicare wouldn’t pay for it because he was on hospice. Hospice told me that they are there to keep the patient comfortable in their final days. If he improves we could always discontinue hospice and requalify him later if needed. I was not allowed to take him to a renal specialist because his renal failure was what qualified him for hospice. You could probably continue to have your dad stay at the facility once the doctors release him but you would have to pay out of pocket. You can always appeal Medicare with the reasons you don’t think he should be released. I know what you’re going through and it’s not fun. I wish you and your family the best.

Yes, Medicare (and other insurance companies) sets the rules. Medicare does not need "approval" of the patient or the family.

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.

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.
.

You can go through Dad's Physician - but with Medicare, they have strict guidelines that must be followed. Sorry, I know it's not the answer you wanted.

We were told that with Out-Patient Physical Therapy and they worked very hard to keep my DH improving. Even so, he was discharged until he was eligible again.

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.

What placed dad in rehab? Is it a terminal condition?

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

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.

there has to be documented improvement -- otherwise Medicare will no longer pay and they will discharge him, and if he's cognizant he can consent to hospice. Even with hospice the family does most of the care--over 99% of it. Hospice mostly gives supplies. If family is unable to do the care, then he needs to go to a nursing home which means he needs to be on Medicaid.

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?

Is your father competent to provide consent for treatment?

Rehab's opinion is that your father will make no further progress with his therapy. Does anyone in the family disagree? - feel that he is making progress, or that he might if it were continued for longer, that is.

How long has he been there? I know other forum members are knowledgeable about how long rehab will be paid for depending on what benefit the patient is getting from it, so I'm wondering if that might make any difference.

Also - isn't there an appeals process or am I misremembering that?

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.

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.