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I'm curious as we start to head down this path (hopefully). With FIL this is such a snail's pace - as we are kind of at his mercy on when we will be able to actually move him to a skilled nursing facility. For the most part he is still competent and is incredibly immobile. He is able to get himself physically out of the bed and using his walker transfer to the bathroom and back, and with the help of his bath aide he is bathing. But beyond that he is depending on the 4 family members (adult children and spouses) for everything else. Primarily SIL who lives in his home and her husband, with myself and his son assisting as we can around our jobs. Many of you have heard our story frequently so I won't bore with the details but long story short we are in the 'waiting for the next big fall" stage with the "unsafe discharge" plan at this point.
Anyway, my point is a question - how do skilled nursing facilities handle doctor visits? I think I had heard that they seriously get scaled back. He thinks of doctor visits as mini-vacations - his social outlet - and schedules them like he is scheduling outings with friends - because he has alienated all of his friends at this point with his behavior (but that's another story). I think at last calculation by year end we will have tag teamed (because his transport to the doctor requires at least 2 of us for safety reasons) him to over 30 doctor's appointments this year. And I would say that if I had to hazard a guess, probably at least 30-40% of those were not necessary. He has three just this week - that require at least on person to take time off of work to assist SIL in transporting him each time.
We are don't have insight into how SNF's work with doctors. Do they eliminate outside doctors in favor of one internal primary? Do they have family continue to manage outside doctor appointments? Does the facility manage appointments and transport? Do they scale down down and eliminate all but the necessary specialists? How does that all work?

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My Mom's Physical Therapist at the Nursing Home made arrangements for her to visit a doctor to check on her broken ankle. NH staff made the appointment with an orthopedic surgeon and arranged transport there and back. A family member had to be present.
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Reply to BernerMom
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I live in assisted living but assume this would be the same for a nursing home. I believe there are doctors on staff who come to the facility to see the patients. Other patients have doctor outside of the home. Either family members transport them or the facility provides transportation - often for a charge and if you need to hire an aide. Either way they must have access to medical people or a hospital.
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Riley2166 Oct 8, 2021
I believe facilities require the patient to have a main or primary doctor but they are certainly allowed to have specialists. Everything is handled by working with the primary doctor,
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BlueEyedGirl94: My late mother did not require the services of any doctor at the NH she was in. After being there two weeks, she suffered an ischemic stroke and they transported her via EMS to the local hospital in that state.
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Reply to Llamalover47
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There is an in-house doctor that sees the patients. For my mom, her 'doctor visit' was the doctor walking in the room, writing something down and leaving. He never talked to her or returned my calls.

However, if he does need to see a doctor outside of the facility, the NH will (should) make the appointment and provide transportation.

When my mom entered the SNF from the hospital, it was for a broken leg. They never contacted the orthopedic surgeon for follow-up care and staple removal. They failed to make a follow-up with the orthopedic surgeon within the time he wanted to see her and when they finally did, I was told 2 days prior that transportation wasn't available. We ended up renting a handicapped van & taking her ourselves. Her surgical staples were in for 40 days by that time.

So, in a nutshell, the facility doctor will take care of his basic needs. Given your dads need for 'social visit' doctor appointments, I think his visits to the doctor will be cut down dramatically and they should provide transportation if they deem the visit necessary.
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Reply to Maggie61r
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I use my own PCP in skilled nursing and my surgeon. My PCP comes to the nursing home. Visits to his office and the surgeon’s office my husband or my nursing home arrange my ambulance transport. The first time I was in for rehab, the nursing home doctor changed my medications with bad results. This time I prearranged to have all my medical care done by my own doctor. I am a diabetic and have to have 4 blood sugar checks a day. Then my insulin is adjusted accordingly. The nursing home doctor messed my insulin up the first time.
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Reply to Bridger46164
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I have found in-house doctors to be dedicated to keeping patients easy to manage and to create the least possible work for perennially understaffed caregivers..

My husband’s roommate had Type 1 diabetes. When roommate finally got to endocrinologist, that doctor put him on scheduled blood test with insulin based on reading, House doctor cancelled because “If we do that for one, we have to do for everyone”. House doctor wanted shot of insulin twice a day done on rounds. No taking time to make targeted dose based on blood sugar.

Like everything, in-house care from doctor depends on doctor. They are hired by administrator. And fired if they crefate too much fuss. And like ll nursing home staff, turnover is high. They seem. To rotate out about every 2 year.
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Reply to BrendaJayi
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Honestly each nursing home (NH) and state regs are somewhat different. And it also somewhat depends on if the NH is also Medicare/Medicaid qualified or not; as well as what the facility type is (Rehab hospital only, skilled nursing facility (SNF), long term care type) as the NH will have many other federal regs that also apply. And also, somewhat depends on who is paying (self/private, private insurance, Medicare, Medicaid or some combo.)

The better NH facilities generally are both Medicare and Medicaid qualified as those federal rules then require many things (RN on staff all the time, "care plan meetings," COVID-related data reporting, qualify of care requirements and reporting, discharge rules, on and on). Most higher-quality NH facilities will have physicians on contract -- or on staff -- of differing specialities that are right there at the NH throughout the work week and on call weekends and evenings; making doctor visits simple (they just come to the room and handle it for the most part there). Most also have other providers on staff right there: dietitians, physical therapists, social workers/mental health providers; and visiting providers like podiatrists, audiologists, and dentists. Most quality NH will ask you to pick a "primary physician" from their list to be your LO's primary doctor moving forward while at the NH (even it if is a temporary stay) to coordinate all the care right there at the facility. Worth looking for a facility which has a variety of board certified physicians on contract or staff right there and even better if most/many of those MDs are board certified in geriatrics; but if not give these providers generally work only in the NH facility, they are much more experienced in geriatric-related care than other physicians in regular practice outside of a NH setting.

When something specific is needed -- such as a specialists not on staff/contract or medical tests/procedures that cannot be done at the NH -- the care team at the NH should schedule and coordinate those limited outside doctor visits. Most NH want to limit the outside visits of any kind -- doctor or otherwise -- because of COVID now. They will also coordinate medical transport as needed. NH have contracting pharmacies so any prescriptions are handled through the NH, don't bring any prescription or other medications (including supplements) to your LO at the NH.

Giving your primary physician at the NH and their care team there the role to coordinate care, make any outside doctor visits is the way to go as those folks at the NH are on point for your LO's care while there. As needed/if needed, the primary physician picked to care for you LO at the nursing home -- and the NH's care team -- will order and coordinate care needs with any health care providers outside of the facility.

If your loved one is difficult about this, let the the NH care team explain how things will be done. Also, worth getting any paperwork done before entering, such as a durable power of attorney (POA) so someone else can handle things -- financial or otherwise -- as needed. Not that you need to take over immediately, but to be prepared if and when you or other family members need to step in more. Ditto, for executing an Advanced Directive that spells out your LO's wishes for medical decisions if he cannot do it as well as naming a "Health Agent" who is the primary person (family member) the NH facility needs to inform if/when there is a "change in status" and the person the facility needs to communicate/coordinate with (family) on behalf of your LO.
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I don't know about other areas, but in the one I'm in, NHs try to connect to doctors at the nearby hospital. It is a win win for the docs, not only are they in staff at the hospital but also become NH doc at NH. If current PCP is not NH doc at the facility, then patient does not deal with her/him anymore unless alive and no longer in NH. Many NHs have a pharmacy they use for prescriptions, which are billed to residents.

Need ambulance or other transport, 2 ways, either charged to insurance, and what insurance does not pay is charged to the resident, or the full cost is paid upfront in full or no transport.
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help2day Oct 7, 2021
Wow. That's pretty rare. Hospitalists are generally not NH doctors. To be honest, they don't have the time to be NH residents' doctors. Most doctors that "oversee" care at nursing homes are physicians at the end of their careers who want to continue practicing but don't want the hassle of seeing patients on a daily basis. They get paid fairly well and generally "oversee" the meds and go over the charts of the patients there. They consult with the NH staff about any patient issues and tweak meds. A resident's family can "consult" with the staff doctor, if needed. The NH can tell you when the doctor is in house as they are not there all day long. It's like a part-time job for the doctor.
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Ideally, you use the in-house doctor who comes to the facility. Not only is it more convenient, that's going to be a doctor specifically skilled in geriatrics (though not necessarily a geriatrician -- they're few and far between).

This is also a good time to scale back on the specialists. The PCP at the facility should be able to coordinate care and prescriptions without endless office visits to orthopedists, pulmonologists, and cardiologists. It's time to refocus on quality of life rather than trying to cure every ailment that in the end is incurable.
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Reply to MJ1929
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Nursing homes most of the time have the residents seeing their doctor and not the patient's own unless it's for a specialty.
The facility is supposed to manage transport and even send an aide with the person who has the appointment. Most of them just send the person to their doctor in an ambulance then leave it to the EMT's to escort them and stay with them during the appointment.
It is up to the nursing home to make sure the resident gets to the doctor though.
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Ricky6 Oct 6, 2021
I would add here that the family can take their LO to see outside speciality doctors, or the facility can do it; as described by BurntCaregiver. Also, they usually use medi-car transportation which is an ambulance car.
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My Mom was fairly healthy when she entered the SNF. Her Dementia is what got her in, the need for 24/7 care and Medicaid. I was given 3 doctor's to chose from. I picked Moms PCPs backup. The dentist and Optometrist were brought in.

I think it depends on the SNF and if your on Medicaid. Moms PCP did not take Medicaid so I had to choose from the Drs affilated with the facility.
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Reply to JoAnn29
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Usually in SNF, the patient is brought to the appointment and returned via medical transport. The facility can manage appointments, SNF also have a staff doctor that they call for non-urgent issues. The staff can also call your loved one's doctor(s) for assistance with medications or problems. In an emergency, your loved one is usually taken to the ER via ambulance. It is best to talk to the facilities you are considering to ask them about how each handles this situation.
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Cover99 Oct 6, 2021
Not everywhere
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I do not have an answer but my father sounds like yours. He needs to be in a SNF but he won't go. He sent home health away and has to have my stepmother's children take off to take him to the doctor, which I feel incredibly guilty about. But he moved when he got remarried after my mother died against my wishes. And my brother moved out of state right after my dad's diagnosis. We are just waiting on the next fall as well.
I appreciate you asking this question, as I have wondered about the Dr. appointments as well.
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Reply to bluebell19
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IF you are able to safely take him to doctor appointments you can continue to do so.
Facilities do have an "in house" doctor that is called in and orders meds, may see someone if needed. (I suspect most of it is just chart review, signatures that need to be done. I think in many cases the Nurse will order a med after consulting with the doctor, for something standard, and the doctor signs off when he/she comes in.) And the house Dr. would renew any continuing meds. Also they would order any lab work that needs to be done.
If a resident is seeing a specialist the facility would arrange transport if the family can not safely take them.
Anything out of the ordinary the facility will call 911 for transport to the local ER
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Reply to Grandma1954
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My brother-in-law is in a SNF, and they use their in-house Dr. or PA/nurse practitioner for everyday things that you'd go to your primary care dr. for. He's taken out by them for needed specialist visits, e.g. neurologist, gastroenterologist, dentist.
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Cover99 Oct 6, 2021
How much do they charge?
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My dad was in a SNF for better part of a year last year and they used an in-house doctor the entire time. His primary care doctor was essentially 'put on hold'. They brought in mobile optometrist and dentist too. He never left for any services. When it came time to move him to memory care, he went to his primary doctor within 3 days of discharge (something about Medicare?).
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There is usually an in house doctor that will care for all residents.
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