Help! Mom broke her hip and skilled nursing says Medicare will not pay.

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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.

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“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’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.
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If you knew the answers all this time, why did you ask for help?  I do not appreciate it when someone ask me for suggestions or advice and then tells me that I am stupid or dumb because my advice does not agree with their opinions.
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bilskro Aug 26, 2018
After coming here I continued doing researching and learned more about the Medicare rules. The odd thing is I don't ever remember calling you stupid or dump. Can you show an actual example of that? Even though I have point out comments that were out and out wrong, I don't even show where I did that to your comments. I just respond with facts.
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What I know is if you turn down therapy 3 times in a row, Medicare will not pay.
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bilskro Aug 26, 2018
No one is turning down therapy. But I guess it is subjective. Ones person trying their best might be another person idea of turning down therapy. In one person's mind maybe if the patient cannot stand and take X steps that is turning down therapy.

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.
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I took care of my aunt at skilled nursing. For Medicare to pay she had to follow their instructions and make progress. A step or two more everyday. To go back to her assisted living, she to be able to go to meals using her walker. Also to get up on her own and go to the restroom. As stated above your Mom needs to get up and move more to avoid other problems.
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bilskro Aug 25, 2018
"To go back to her assisted living, she to be able to go to meals using her walker. "

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
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Bilskro, your goal of getting Mom back to her assisted living arrangement may be dependent on a couple of factors ..do they accept residents in wheelchairs and do they accommodate 2-assist residents? I don’t mean to discourage you, but the assisted livings in my area do not take either. Residents have to be able to walk to the dining room on their walkers. This was the big let down in our plans for Mom.
I found that dealing with the rehab progress after Moms falls and surgeries to be one of the most stressful and frustrating parts of this this journey. I was at the PT every day, stressing out over whether she could take one more step than the prior day. Trying to arrange the perfect time for her therapy, cajoling the PTs to let her walk first before additional exercises, nagging her to keep going through pain. The therapists knew she had to progress even a little to stay in the program another week, so they did everything they could to get those extra steps from her, hoping another week would made a difference. Also we were trying to get her over the hospital dementia, and we didn’t know how long that would last, or if it was having an affect on her ability. It was hard on everyone, but I really felt the therapists were on her side. Finally after weeks at rehab we all agreed she had plateaued, and it actually was the biggest relief. She went into long term care and the PT started up again. Same cycle but she did much better there. I think the hospital fuzzies we’re finally wearing off. Until she plateaued again and was out of their PT program. I continued to work with her one on one and aides were instructed to walk her to meals. That was as good as it was going to get. As far as your comment about “maintaining”, at the NH when she started to be unable to walk to the dining room 3x a day, she qualified for PT again. Until she plateaued again at a lower level. Then that would be the new baseline. When she fell under that level, again the PT would start again, maybe not much progress, and a new baseline. So that’s how the “maintenance” cycle goes. Sometimes it’s just not possible to continue to progress due to age, health and other factors.

That being said it’s very important to be an advocate and involved all during therapy. I hope the meeting Monday gets some results.
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bilskro Aug 25, 2018
rocketjcat,

“do they accept residents in wheelchairs and do they accommodate 2-assist residents?”

They do which is why we choose that place, but you are right it really is arbitrary and up to them to decide. I meet with the executive director when I was in town and when mom first moved to the assisted living place and hammered this point again and again. I was clear we do not want mom to go into a nursing home and if anything happened do they take the patient back after surgery or skilled nursing. They told me they do everything in their power to keep a resident once they are established. For example they cannot take a 2 person lift resident as a new resident but will keep a resident if they digress into a 2 person lift.

I see people there that are in wheelchairs who cannot do anything. Most residents there are in wheelchairs. The do charge more based on level of care needed. My mom was at level 3 their highest level of care. But they can also say if you cannot pivot we will not take you. It really is up to the executive director. 

“I found that dealing with the rehab progress after Moms falls and surgeries to be one of the most stressful and frustrating parts of this this journey.”

You are not kidding. Very little empathy out there or understanding on how everyone is different. Just because another person or their parent was up and running in a week has nothing to do with this situation. We are trying everything including paying for and hiring some of her previous caregivers to come in and encourage her to eat and exercise. I hope others don’t have to experience this so they know what it is like.

Plus there are just so many other issues going on the same time. Like her pain medicines were affecting her mental state and making it extremely hard to communicate so the doctor tried to switch her and that made a huge difference, but then she is in more pain. Nothing is easy!!!!

“She went into long term care and the PT started up again. Same cycle but she did much better there. I think the hospital fuzzies we’re finally wearing off”

I have a story along those lines. She had fallen before and went into skilled nursing and did PT and when she came out I saw no evidence of improvement what so ever. She could not get up or sit on her own moreless walk with her walker. She then started outpatient rehab and Wam Bam she was back walking with her walker in a matter days. I personally think skilled nursing treats patients terribly. This is a true story. I go to skilled nursing and they have all these patients just lined up in front of the desk in their wheelchair. They looked so miserable and my mom was there and super upset that she was just left there for 2 hours. So I ask the person behind the desk why is mom just sitting out here for 2 hours and she say, “They put the patients out there so they can keep an eye on them and they are waiting for PT or OT and they are happy”. Happy!!!!! you must be kidding. They were all miserable. It is beyond SAD!!
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It’s really important for a post op hip patient to get up and walk. I understand that she is 84 & in pain. DeeAnna gives some great advice above especially pre-medicating prior to PT for pain control.
I understand incisional pain can be awful but your mom has to work through it. She will never be at “zero” pain level. But your mom’s hip joint pain should be way less that before surgery- that’s what the surgery fixes.
Taking only one step 7-10 days post op is not progress. Whether it’s a language barrier or not, she has to get moving.
What was her level of activity prior to surgery? Was she an active person or sedentary? Does she have any other barriers like obesity or other diagnoses that add to her difficulty walking?
Getting language “flash” cards for her & the staff to use is a great idea.
If she doesn’t start moving her recovery will be longer. Someone in her native language needs to tell her that. Telling her they may keep her longer may motivate her to step it up a bit as I’m sure her goal is to go home and not be either in rehab or the LTC center.
She needs to walk to prevent blood clots, prevent muscle atrophy from misuse, and prevent constipation and prevent pneumonia from post op anesthesia and not deep breathing.
Did she know the expectations for rehab prior to surgery?
As far as the Sebelius lawsuit you cite above I wouldn’t count on that lawsuit preventing the rehab staff from suggesting she needs LTC due to slow progression. They have written standards with goals that must be met for post op hip patients & if not met they may extend her Medicare rehab days a little longer but if they don’t see an improvement or any “buy in” on the patient’s part, yes they will recommend a long term care facility stay.
I had my hip replaced at age 60. Granted I’m not 84, but they had me up and walking by 6pm the night of surgery. The PT staff followed me around the nurses’ station with a recliner just in case I needed a rest. But all this was explained to me so I expected this.
Maybe you can visit and explain all this to mom. Make the expectations clear to her. She really does need to walk more than one step a week or so after surgery.
Great advice from all. Best of luck to your mom and family.
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bilskro Aug 25, 2018
Shane1124,

“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.

“They have written standards with goals that must be met for post op hip patients “

I have to disagree with you. The PT should not be setting the standard, but in my opinion the Doctor, preferable one that knows the patient history should. This is one of the problems to me that you have a PT who knows nothing about the patient’s history setting what they think her standard should be.

That lawsuit was clear if a person needs PT just to maintain or not go backwards Medicare will cover it. You can disagree with the lawsuit but I actually agree with it. That is why we are going to talk to the surgeon that ordered the PT to see if we can get realistic goals. 

I agree it is important for the patent to move, but if they cannot take a step or enough step right away then moving on the bike or other exercise are just as important. The rehab should be based on getting her back or what is reasonable back to her pre surgery condition and she was not running laps before surgery as I explained.
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Bilskro,

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.
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bilskro Aug 24, 2018
Tothill,

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.
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I think I might be tempted to ask her doctor for intervention. She’s worn out, she’s in pain, she doesn’t understand what the PY is asking her to do, they come for her in the afternoon when sne’s tired...this sounds like a real set-up for failure. The. Jose’s and therapists have to follow doctor’s orders. Ask to speak with the doctor directly. Sometimes orders get lost or are t
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Ahmijoy Aug 24, 2018
Sorry. Was typing in bed at 4AM. Anyway, ask to speak directly with her doctor and tell him/her what’s going on with your Mom. A new plan for Mom needs to be formulated because this one isn’t working. I feel bad for your poor mother. She’s trying and they aren’t setting her up for success. Come back and let us know how it’s going for her.
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DeeAnna,

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.
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DeeAnna Aug 24, 2018
Bilsko,
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.
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It seems that the language barrier is a HUGE part of the problem.  It may be that the physical therapist and occupational therapist are assuming that your Mother is REFUSING to do therapy (which is a valid reason to stop Medicare therapy) when your Mother is actually stating that she can not do the therapy because of pain.  You need to meet with the physical therapists and occupational therapist to claify this immediately.  Suggest that they use the FACE PAIN SCALE that shows faces from smiling to frowning (0-no pain to 10 worse pain) so that your Mother can indict the level of pain that she is having when she is doing the therapy. 

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?.
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