Medicare/MediCal won't cover a bed for my grandmother with mild dementia...what are we supposed to do?

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We need to find a facility for my grandmother, but because of mild dementia she will not be covered. We can not afford to pay for her care. What can we do? She can no longer stay at home with my parents. Caregiver burnout is tearing their health and marriage apart...please advise

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NeedG - the hospice you all are using should be able to provide the info on how to request respite care for the caregivers (your parents) and help with the placement at a facility for grandma for the week or so of the respite stay.

well if she is a Spanish speaker it will all be OK because the vast majority of the workers will be Spanish speaking and 1 or 2 of them will "adopt" her as she reminds them of their abuelita or Tia Ma.Louisa. No va a ester una problem si ella habla Espanol. If she speaks an odd language, like Albanian, well you are stuck. But at some point with dementia, language goes so they all are in the same boat.
My grandma was in a NH (so we are 2nd generation of having elders in NH) and spoke only Spanish; she became special friends with a gentlemen who spoke only German (he was from the TX Hill Country and his kids lived in San Antonio). They moved about the dining room and activities room as husband & wife and spoke to each other in their own language, happy as clams. He did look somewhat like my grandpa but his way of dressing was so like my grandpa.

Kaiser - nice! Since Kaiser is huge, this may take some work. They will have some sort of community health service or outreach program, usually based at one of the large health care facilities which has a teaching hospital component. You want to talk with a social worker within this program as to what is possibly available for your grandma. You have to be relentless as your grandma's advocate. Do you know why she is being turned down from facilities exactly? Has she been tested for where she is within the dementia scale? It could be that the way you all describe her isn't accurate for how the facility would evaluate her to be. So recent testing by the gerontology department (usually will be 2 doc's - gerontologist and neurologist) along with an evaluation of all her medications and changes, might make her an easier placement. You parents are overwhelmed and really all this, doing research on-line, calling about, making appointments on line, will be easier for you and your more internet savvy brain than for them. Thankgoodness you are there for them.

You know 5.5 million folks in the US have Alzheimer's, so that means like 15 million are daily affected by the disease. (this I just heard on the Today show which I have on in my office) You are not alone. But that also means you have to work hard to get grandma into a place because there are lots of others in the same place looking for someplace for grandma.
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@igloo572 Yes, she has Kaiser
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Hi igloo572. I really appreciate your advice. Sorry for the delay in response. As all caregivers know, there are fluctuations of good times and bad times, right now it is particularly bad. Not so much for my grandmother, but my mother who happens to be the target of my grandmother's verbal abuse. My mom suffers from major depression and this abuse is driving her to the edge of her sanity. But back to my grandmother...she has MediCal (Ca's version of MediCaid). As far as I know, my dad has POA and says that her only income and assets are SSI. When we toured facilities, we were told that she would not qualify for a MediCal bed because of her dementia. The other thing is language. She does not speak any English and therefore, it limits the amounts of suitable facilities.
With respite care, I meant a break for my parents. I was reading that is sometimes an option for people who have the burden of caretaking.

I will make sure that the things that you mentioned regarding her needing help with meds, patches and such are documented in her medical files.

If you have any other suggestions they would be much appreciated. I feel like we are working on borrowed time right now with my mom and her sanity. I feel so helpless sometimes...Thank you so much for your insight.
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NeedG - Is it Kaiser? They have full gerontology departments so if she isn't being seen by a true gerontologist (not a family medicine doc or a regular internist), I'd look to get the referral to be seen by someone in gerontology dept - it may be that you have to drive to a bigger hospital/medical center for this. For the elderly, being seen by a gerontologist is like a child being seen by a pediatrician, specialized care for a specific phase of life.

The 8 months was the period of time in which we (my mom & I) started seeing the gerontology group every 4 - 6 weeks to build up her need for skilled nursing by and have it documented in her medical file. Then once in the NH it took about 6 months for her to get totally approved by Medicaid. I worked her $ spend down during the last 2 years she was in IL so financially she could be under Medicaid limits.

Do you mean your grandma is on HOSPICE? Respite care sometimes means hospice. Hospice is covered by Medicare and provides health professionals to go to your house or the NH, to do that. Now if they are on hospice, there is a caregiver option in which the elder (your grandma) can go for a short-term placement into a facility so that the caregiver gets a "time-off". I've never done this or know how much time it is, but I think it's a week minimum. They also can get a short placement into a NH while something needed is being done at the home, like a ramp being put in and they need to be away as they would be trapped if something happened while the ramp, new doorway, whatever is being done. I think that since this is Medicare, the medical part is covered but usually the room & board costs of the facility isn't. Maybe someone else on this forum knows???

However, I do know that often the elder's family uses the caregiver time-off to find a NH for the elder to move into and the facility works with them to get the evaluation done to make that happen during the week they are there. One of the ladies @ my mom's NH went for respite stay at 3 different NH, and then when she & her family was at the point that she couldn't be at home anymore, she went into one of those. Kinda ideal as everybody already knew each other. Smoother transition & less stress.

Do you know if grandma would qualify for Medicaid for the financial review?
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Thank you for the helpful information igloo572. I have so much to learn about this process. She belongs to a HMO, so I am not sure about changing doctors. I will look into that. Did it take eight months from start to finish for your mother to get into a NH? Do you know anything about respite care? Would one be able to transfer from respite to Nh? I don't know how much longer my parents will be able to care for her. She is sooo demanding and abusive, it's really taking a toll on the mental health of both my parents, but especially my mother. Trying to look on the bright side and keep positive.
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You know this situation is pretty common as most folks fix on the financial aspect of Medicaid & totally miss that they have to medically qualify for needing SKILLED NURSING CARE. Just being old, or forgetful or a pia alone doesn't work

Do you know if she for sure, positively qualifies for Medicaid financially? In other words, do you still need to do a spend-down on her assets and income to get to whatever CA has as it's ceiling for income & assets to qualify for MediCal? If so, then you have to deal with all those aspects too.

But if not, you are going to have to be creative to do this but it can be done. Most NH admissions come from them having a hospitalization (like due to a fall) and then they are discharged to a NH for "rehabilitation" and then they end up staying in the NH after rehab days are done. When they go this route, there is a fat medical file that will easily pass the skilled nursing needed review.

But moving into a NH and NOT coming from a hospitalization is more difficult as the medical need is not documented. I moved my mom from IL to NH and totally bypassed the AL stage. My mom's old IL (which worked great for her for a good while) was part of a tiered system that went from IL to AL to NH & hospice. I thought that it would be just perfect as she could move along their system as she aged and her money aged and decreased with her. Yeah, sure, good idea, right! So wrong! as the facility really wanted her to move from IL to AL and that was the position they would take - I can understand that as AL is all about private pay and is the profit center. But there was no way we could or would pay for AL which they felt she could stay in for the rest of her life.....so in other words they weren't going to help me get her into the NH part and on Medicaid to pay for it. So the medical staff for AL & NH were not going to be helpful. I had to come up with Plan B.

This is what I did instead: the main thing was to get her gerontologist (which was not affliated with her old IL/AL/NH facility) to work with me in getting her medical chart worked so that she would meet standards of needing SKILLED MEDICAL CARE. This meant appointments every 4 - 6 weeks and tests 7 diagnostics run that could more closely monitor changes. (I live in another state and would come in to do this with her.) Now the doc's in this practice were/are medical directors of NH's and so understand how a chart needs to read for NH acceptance. They are also affiliated with the gerontolgy dept of the medical school. My mom was going to go into one of their affliated NH when she was at the point of doing this.
There are simple things an MD can do - like change a medication from a pill to a compounded medication - which can't be done on their own independently. For example, if your grandma has issues swallowing then the MD can change a medication to be compounded. Or change a med from a pill to a patch (like Exelon), which again they can't do on their own (they can't place a patch in the center of their back). Understand? My mom was in IL so there was no kids to help her do this, so you need to impress on the MD that your parents or the grandkids can't do this for your grandmother and that must be notated in grandma's chart.

If I were you, I'd find a group of NH that take MediCal and that you like and find the names of the MD's who are the medical director and then get your grandma to become a patient of theirs in their private practice away from the NH. Their NH is going to be the NH that she goes into. Now it may NOT be ideal or your first choice but the important thing is to get her into a NH. You can move them to another pretty easily - I did this with my mom and into a much, much better facilty within her first year. Medicaid rules totally allow for this as the NH gets paid by day rate and it's done all the time.

There are tests that can be done to monitor their health over time that will allow the MD to write the orders that skilled nursing is needed. For my mom, the visit that she had a critical H & H level and had lost 10% of her weight since her last weigh in and a couple of other medical concerns, was the visit that she got her NH needed paperwork aka "skilled nursing needed". So she had a 30 day window to move into a NH and I moved her to the NH that had a bed about 3 weeks later.

Once they are in the NH, the state will send someone (maybe an RN and a MSW) to evaluate her and her medical history to see if she qualifies for needing skilled nursing care and that the facility she is in can do that. Now since the medical director was also her physician before the move to NH, all her medical history, chart, lab tests, from his private practice medical records will be in her file @ the NH. This should create a nice, fat file and believe me the state workers aren't going to go into detail to read it.....if it's got lots of stuff then probably it's good to go. There can always be glitches with all this, I had some with my mom's prescriptions getting left off of her in-take report Day 1 @ the NH. But since her MD was also the medical director of the NH, it was simple to deal with. All this took about 8 months to do and she went into the NH "Medicaid Pending".

I've found that non-gerontology MD's just can't get the charts done to pass a skilled nursing needed review if the elder is still living at home. Your state should have a list of Medical accepted NH and within the listing should be the name of the medical director(s). I'd start with that list and work it to find a place for grandma.

Hope this helps, Good luck and keep a sense of humor.
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