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An 82 year old friend (w/ dementia) has been in a psych unit since December and is now being discharged in a few days to a long term care facility and is medicaid pending. Does his family (they live four states away) have any say into which facility my friend goes to or does his family have to "take what they can get"?


The psych unit (social worker) has found placement but the family isn't too sure of the long term care facility based on Medicare ratings. Can the family demand that the patient "wait" at the psych unit for a better option or does the family need to transfer the patient later if the long term care facility doesn't work out? Thanks for any input!!

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Yes you can choose the facility. If her time is up at mental facility here is what you have to do, we went through this last year with my aunt.

"THEY (mental facility) CAN NOT RELEASE YOUR MOM IF SHE DOESN'T HAVE A PLACE TO GO" Please don't back down, tell them you are UNABLE to Care for her and by law she can't be released if she has no safe place to go. If you have to put her in the facility the social worker found then do it while you are looking for one you like. Some won't take her because she is coming from a mental facility. Good luck, Stay Strong. Positive Thoughts.
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worriedinCali Feb 8, 2019
The OP is a friend not a family member. It’s not his/her mom. The OP has no say in the matter. The woman’s family are several states away.
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Yes, if Medicaid is paying or they are wealthy, make sure the care facility meets your standards. Do not be guilted into expectedinf anything but the best of care no matter where they r. It’s your job now, to make sure they receive the best care or at least the best of minimal care available. I’m a survivor of Huntington’s. I keep them on their toes. It’s a must.
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If the hospital is ready to discharge you should be involved in the discharge process. However, finding a Medicaid approved bed is sometimes difficult and they may be limited in there choices. I would recommend the following:
1. Asked the social worker for a list of facilities with Medicaid approved beds.
2. Tell her that you will go and tour these facilities immediately and let her know which home you would like your loved one transferred too.

Potential Problem
It is much more difficult to find a home that will accept a resident when they are "Medicaid Pending." Homes are not sure if the Medicaid will or will not be approved and some homes do not want to risk that the resident will not be approved and they will be left with a huge bill.

Good News
Once the resident is Medicaid approved you can move them to any Medicaid approved home you choose. It is not difficult to move a Medicaid resident from one home to another.
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shad250 Feb 8, 2019
He's a friend not a family member
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Just went through something like this.
1. Live 1000 miles from younger brother who needs LTC. Unable to travel to him due to my own health.

2. From hospital I was given news that he could not live alone anymore due to "Self Neglect". I was told by SW that she would look for a facility for my brother, she gave me several but I will say that there are not many beds available and finding a Medicaid bed is really hard. Most places want ..... not too sick, quiet old ladies, who are Self Pay!!

3. I contacted my brother's personal doctor.

4. Doctor gave me names of LTC facilities in which HE has affiliations.

5. Communicated list of LTC to SW and she made sure they also accepted MEDICAID.

6. Brother has some money from small IRA which he must spend down to get Medicaid. He will do this quickly as he doesn't have a lot of money.

7. He was sent to a facility for rehab, and will transition to LT in same facility. He is Self Pay and got in immediately...., but the facility must also offer a Medicaid bed for the future, as he will run out of money soon. I do not want him moved again when his money runs out. ( NH LOVE self pay.) In NJ over 65% of all folks in LTC are on Medicaid or heading toward it as their funds run out.

8. In NJ be prepared to pay over $10,000 a month until the patient has "spent down" to $2,000.00 in assets. Patient's are allowed $50 a month while on Medicaid for personal items...everything is taken, SS & whatever else while on Medicaid.

9. He has a small home which also needs to be sold, old car.... must sell everything to get down to the $2,000.00 threshold before Medicaid steps in. Spend on anything else except the patient and the patient will be penalized by Medicare by the amount miss-spent.

So, yes, you should get a choice. BUT you may only have one choice. I did find out that the care is the same whether you are a Medicaid patient or Self Pay. CARE DEPENDS ON THE DOCTOR!! So, my suggestion is to find a place where you or someone else knows the attending doctor for the NH.

This is a very stressful part of life for family or persons who help someone else in need of special care. My prayers are with you. I know how difficult this can be and it doesn't always turn out the way we think it should.
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Llamalover47 Feb 4, 2019
Gailbry: As far as Medicaid goes, a house and a car are non countable assets.
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Firstly, a Medicaid bed must be available for the patient. The patient's countable assets for a Medicaid applicant is generally $2,000 (but not for all states). That amount would then be taken up by the facility for the patient's care.
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Gailbry Feb 5, 2019
thank you very much. I have been told that the assets, not money, must be spent down to the $2,000.00
GB
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Tell family to tour facility & see how residents look & if place smells clean. Talk to some residents to see how they like it there. Most residents always say they want to go home..which can mean their childhood home
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As long as this facility, Which One should make sure they have checked in to make sure it is the Good One, hun, Is Accepting Medicaid, Then let them go there. No, They don't have to "Just take what they can get," But if it is something that is Finer down the Line, Take it. The grass may not always be Greener on the other Side of the Financial Fence.
The family, If not too Pleased, Would need to Talk to the Social Worker in Charge at this Facility to Talk more about this.
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Nursing homes are places where people check in and don't check out. Institutionalized "care" will kill them more than anything. In many cases you will be put on a waiting list until someone else dies. Beggars can't be choosers when it comes to Medicaid.
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Hi, I'm a Social Worker at a LTC facility. Here's what I know. It sounds like a hard situation. In an ideal world, the family would be given a list of facilities that have a Medicaid bed available so they can go tour and make a choice, but this is not always realistic and here's why. First, finding a Medicaid bed in LTC is very hard because each facility only has so many medicaid beds available, and well, once a patient has one of those beds, they often stay a long time, so beds rarely come up. In my area, the SNFs that are highly rated don't even take LTC Medicaid patients at all. It seems that the lower rated facilities are the ones with beds available, unfortunately. Second, if a SNF that had a LTC Medicaid bed available, had the choice to take a new patient with Medicaid in place already vs one whose Medicaid was still pending, they may choose the one with the Medicaid in place already. Third, if there is a facility with a rare Medicaid bed available, it will certainly not be available for long since there are so many other patients looking for a Medicaid LTC bed, so there is not a lot of time to make a decision. As long as the current facility social worker has been communicating with family and documenting their many attempts to locate a facility that the family would prefer, but without success, there is no other obligation except to find "a" bed, not a "preferred bed". Once a discharge order has been written by the doctor, I have 3 days to move a patient. I hope this sheds some light on your difficult situation. Best Wishes.
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Reply to SofiaAmirpoor
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Yes you may choose and no you can't.

The facility must have a Medicaid spot available. If not then not.
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Reply to donkeehote
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Yes, the family can insist that several options be given to be check out. However, facilities really need to be seen, not just looking at their ratings.
Don't let the SW bully you into anything. The SW's job is to get them out asap. I, unfortunately, encountered this myself...
Medicaid beds aren't that great to begin with. I found that Senior Group Homes offer a small environment with better care than ANY facility out there, even the expensive ones.
However, that was chosen because he was wheelchair-bound and had no interest in or outside events. He's content to watch his old movies and have visitors from time-to-time. He's very private.

All the best to your friend!!
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About the whether a NH takes a resident, I’d bet that the “psych” diagnosis reads they need a locked ward for care with higher level of “medication management”.

What my understanding is that when it’s this duo in their health chart it’s especially difficult placement..... the locked ward can be MC / memory care. MC in & of itself is not necessarily SNC / skilled nursing care. MC isn’t necessarily covered by LTC Medicaid funding. LTC Medicaid $ is required to be “dedicated” (required) funding for skilled nursing care. Whether a state wants to use its Medicaid $ to include MS or AL, is up to your states Medicaid program to do this as a waiver program. Most states Medicaid do not ever pay for AL. For MC it seems to be abt half or so do.

Then coupled with the above is that “medication management” too may not may not reach the level that requires skilled nursing care. If it’s just set RXs 3 times a day, that might be able to be done by a Aide or CNA and not technically needed skilled nursing staff. It medication wise, they are now under control and reasonably functioning, they might not need skilled nursing oversight. Yeah it’s not simple.

That place with an open bed may be the only choice. And they need to move in now while still an opening. Believe me there will be another patient who will take it as it’s can’t be left waiting indefinitely.
There are no other options unless the family signs a contract to private pay for a psychiatric LTC facility.

at 82, if you don’t mind me asking, just where has the family been all this time? Do you have any legal standing in any of this, or your just a friend or neighbor? Or did something happen, that caused the situation to snowball unexpectedly?
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Onlychild, if you’re strictly a close friend with no DPOA, no MPOA, no signatory on her banking, no HIPPA release, etc already existing between you and your 82 yr old friend, there’s not much you can do unless you want to totally private pay for her care and take on full financial responsibility for her. And unless you’re Uber wealthy that makes no sense to ever do. Yeah it’s a harsh reality.

it sadly doesn’t sound like she could go back to living in the community or living independently. She needs a psych ward, locked care type of living situation, right?

Her family states away either need to step up and be in your city to deal with their family member (mom?\aunt?) and either do whatever needed to get her thru Medicaid eligibility and placed into a facility that meets her needs. Whether that takes going back & forth for weeks or more. If no DPOA already done, and if she’s not really competent and cognitive that means trying to get guardianship. And they need an atty in your state for this. Guardianship like Medicaid is state specific. If no family member actually is a resident of the state, it may be that what is considered best is for her to become a ward of the state of where she lives now with a court appointed guardian named that oversees her finances and eligibility for whatever programs available. Often the court appointed guardian can get things expedited way way beyond what regular folks can ever do.

If her family doesnt start to do something tangible, the facility where she is now will likely do the following:
- 30 day notice sent to family and anyone else who may have signed off on her paperwork. 30 days to either to move to more appropriate facility for her level of care or someone signs a legally binding financially responsibility contract. Private pay psych facility will be very $$$$.
- CC of the 30 day to APS, so that APS is on notice that they could be asked to intervene in 31 days
- CC to whatever probono legal clinic in your state. This doesn’t mean the legal clinic sent has to deal with it, its more imo of a CYA for the facility that someone legal has been notified. Most probono clinics do NOT deal with these type of issues. Where I live there’s 2 law schools and both probono mainly deal with juvenile justice issues.

If nothing done, then after day 30, APS is asked to seek an emergency ward of the state status for the resident. Judge grants a temporary guardian and usually the guardian comes from an already vetted list that the court has. Guardian can then move her to another facility if need be. But they are in charge. After like 90 days there will be a hearing on the temporary status, and at that hearing family or whomever can petition to become guardian.

Unless her family can either care for her in their home in another state or private pay for her in the new state till she is able to establish residency, there may be no real options but to let her move into the only facility that will accept her (whatever their “ratings” are).
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So it isn't just the choice of facility, it's also the daunting state transfer issue.

Well, perhaps the family had better start with the end point: see if they can find a facility that would hypothetically would be ideal, and then beg support from the facility's admissions team + their own state's Medicaid system. These are the people who will know how you find the way, if there is a way.

The big point they have on their side is that it would undoubtedly benefit the patient to be near his family - the transfer would be in his best interests, and all those who have any responsibility for his welfare are obliged to take that into account.

But other than that... Gulp. Good luck.
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I spoke w/ the family and it seems as if none of the long term facilities want to place the patient due to Medicaid! They were told by the psych social worker (today) that nursing homes would rather have private pays so they turn down the Medicaid patients. Is this something that you think is true or do you think it's because of the "psych" diagnosis?
The family would rather have the patient relocated to the state that they are in instead of being so far away. What other options are available? Money is very limited. The family did do their best by having the Medicaid approved but now it looks as if it's not enough. Obviously, Medicaid is not approved for the state that the family is in so that's a complication.
We'd appreciate any input/information that you may have to help, thank you!
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worriedinCali Jan 31, 2019
Its true. It’s not really the psych diagnosis but that could also be a factor. These facilities are a business. They have to make money. Medicaid does not pay much so most facilities have a limited number of Medicaid beds. they also tend to save private rooms for non-Medicaid patients. They make more money off non-Medicaid patients. My FIL is on medi-cal which is California’s version of Medicaid and hasn’t been able to get a bed in a rehab facility either. But now he’s got a chest tube and that is what is now keeping him out of rehab and a nursing home. If he can’t afford to self-pay and his family is unable or unwilling to pay, his choices are limited. There really aren’t any options other than to send him wherever he can get a Medicaid bed. If they want to move him to another state, they not only have to apply for Medicaid in that state and start that process but they also have to find him a facility. It is difficult to transfer from one stars to another. Also, some states require you to have lived in the state for a certain amount of time before you can get Medicaid. So......he may not be eligible for Medicaid in the state his relatives are in.
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Short answer is yes; they have a choice. Concern is availibility. The family cannot insist the psych facitliy hold the person; the psych facility needs the bed for other patients and if a place has been found they will need to take it or discharge the person to their home. Also, Medicare will not pay for it if it's not deemed neccessary anymore. There is a huge price differance between a psych stay and long term care. The family could also look for placement around where they live. Call up places and see, talk to social workers from the areas they want placement. Psych patients in long term care usually don't work out. There are also smaller private homes that are options called adult foster care homes. The issue would be the diagnosis and potential for dangerous behavior since he is a pysch patient. They're are also homes that are a ladder down from long term care and some take only a certain type of patient like memory or psych ; there are all kinds of options. Research is needed by the family.
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They do not have to remain at this facility for the rest of their life.
Medicaid allows for a lateral transfer if the new place can provide the level of care needed.

Now doing this will be a total ballet to accomplish imo. Timing mucho importante! I moved my mom from No 1 to NH#2 at about month 9 and AFTER she had gone thru the Medicaid Pending phase and been totally Medicaid eligible. #1 had morphed beyond what I could deal with administratively, like 3 administrators, SW left & vacant, chronic billing cockups and the last straw was the medical director - who had been her gerontologist prior - was not going to renew his contract. Anyways I found another NH, that had gerontologist from her old group as medical director there, and they had open beds. I did a evaluation request and hippa release form to new Nh. Admissions from NH #2 sent out a 2 person team to visit mom to see if they could provide the level of care needed. They actually called me from mom’s bedside to tell me she was all good as far a ps they were concerned for lateral transfer. I went next day to new NH to fill out transfer paperwork that #2 would send to the state and then faxed over a notice of move with exact date to the corporate HQ of NH #1. It was about 8 days before EOM.

Now this is the sticky part, the month of the move BOTH NH must be paid the exact copay or SOC (share of cost) due for that month. I did NOT have NH#1 as the rep. Payee for mom’s SS and civil service retirement; she continued to have it direct deposited into her checking account and I paid the NH the exact to the penny as per Medicaid eligibility letter check every month. I as moms dpoa still controlled her monthly income and the $60 a mo that remained behind each mo as her personal needs allowance. If the NH is this lady’s payee, that system will need to be changed and this may not at all be easy...... the old NH - especially if it’s part of a chain - could footdragg to forever to release their payee status and it’s not like the lady can run down to SSA office to do this in person..... Anyways I scheduled the move for like the 6th of the month. So after mom got her paid on the 3rd of the mo SS & usually on 4th of the mo federal retirement $, so both NH got paid by checks to the penny for that months copay divided by the # of days in that exact month. Also ahead of all this, as the writing was on the wall, that this NH wasn’t working out, I got her personal needs trust account down to zero and either took her out to visit her old beauty salon or paid in person the at the NH beauty shoppe directly for mom’s visit.

NH2 let me set up mom’s room the day before, so I got basically everything moved out ahead of time & got photos, clock, new curtains up, closet filled and spoke with her abt to be new roommate. The new NH required that she be there by 10/10:30 and be able to go to lunch there the day of move.

Also - and this is super important- you have got to get all her medications. For NH they usually are done in 90 day blister packs held on hangers or in 90 day jars in a locked closet at the nurses station. New NH really stressed all meds must be taken as Medicaid &/or Medicare will not pay for duplicate medications. And some meds require extra paperwork if they have to be reissued within a 90 day period. So if you don’t get her meds, you will have to private pay for all her prescriptions and this could be quite expensive. I was totally prepped, with pint ziplocks and Sharpie markers. The floor nurse was especially hostile and basically dumped mom’s meds on the countertop. Ziploc to the rescue.

My mom was ambulatory, so she was able to ride in my SUV. Drove to new NH and in plenty of time. They did a new resident announcement at lunch and had her at an activity later that day. The new place has got to, got to, be at the ready to work with you on doing the transfer.

It can be done but as I said it’s a bit of a ballet as it has to synchronize on all sorts of levels.
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GraceNBCC Feb 12, 2019
Great information. I had bad experience some years ago, ended up discharged because I would not self pay for 3 days in hospital for testing. I had private insurance then, and a mortgage. Amazing how I got cured while in the hospital for seizures.
Now on Medicaide and independent Sr Living.

People make assumptions! After 5 days at 2 hospitals..all observation admissions...was being pressured to go to a NH. I finally said, I have $35, which NH would you suggest?
Without 3 day Regular Admission, Medicaid won't pay. Took over 5 months from approval of Medicaid Waiver, to first services. Also 5 months from ending Home Care to start of Outpatient Care.

Let's just say the state will be fully informed of Medical neglect and negligence on the part of my now former PCP. The Waiver delay..plan on it.
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Has the family picked a better option and does that place have Medicaid beds open? That’s the million dollar question.
Also can they tour the facility that has the open bed after studying the Medicare write ups? It’s very hard to judge facilities solely based on the Medicare ratings without seeing them. A 5 vs a 1 would be red flags, but a 4 vs a 3 isn’t so clear, or maybe not a really big deal. If the desired facility has an open bed, there should be no problem requesting that facility. If not, you need to find out how long the psych unit is willing to wait.

When mom was being released from her rehab Medicaid Pending to long term care, the rehab social worker was very accommodating. They had open beds at their attached LTC building, but I didn’t want her to go there, as it was a long distance from me and I was driving it daily. So I applied to my #1 choice closer to my house. (A 4 Medicare rating) Rehab said they wouldn’t kick her out while I waited for a bed to open. And I waited. And waited. Finallly after another month I just couldn’t take the drive anymore, the #1 choice still didn’t have a bed, so I took our #2 choice (a 3 Medicare rating) But it was close to my house and since I was going almost daily I figured I could oversee or compensate for the lower rating. It worked out fine. My point is having an available Medicaid bed is vital to their choices. It is possible to transfer between facilities later, but I haven’t seen it done very often in my experience. The devil you know is better than the devil you don’t, so to speak.
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Does the family have a better option in mind? Is there a specific facility they would like their father to move to?
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The family should discuss this with the social worker. If they're not happy with the choice of facility this is something that needs to be discussed.
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