Mom wants to leave the skilled nursing facility against medical advice. Why won't they clear her?

Do not have her leave AMA! If she does then, likely, her insurance will not pay for her stay. And she can't afford the copay now. What if she were billed for the entire stay?

I would seek a second opinion from her own doctor, not the doctor at rehab. I am assuming they are different and employed by different employers? If that doesn't work call Medicare to discuss the issue. There is probably a policy in place to address these sorts of issues.

I told them when Mom went in just to get her strength back, that she was only staying the 20 days Medicare paid fully because there was no money for the $150 days after that. She was discharged in 18 days.

Go to the finance office and tell them Mom has no money for the extra days. That they need to discharge her or agree not to be paid. Bet she is discharged. Mom can do therapy at home, I think. Check that out with insurance provider. If they do nothing, call her primary. If get nowhere with that, call your state Ombudsman.

I really hate Rehab facilities; they can sometimes CREATE more problems than they cure. When my dad fell & broke his hip in 2014, he wasn't making 'proper' progress in Rehab so they insisted on putting him in their skilled nursing section which was a DUMP and something we couldn't do. His PT did everything in his power to PREVENT me from getting him *and my mom* into an Assisted Living Facility!!!! He promised to tell the ALF that dad was in NO shape to live there and that he belonged in Skilled Nursing! He threatened me on a daily basis and my anxiety level was thru the roof as a result. I finally told him OFF, suggested he speak only the truth to the ALF when they called and to leave his personal feelings & opinions OUT of the conversation. Dad wound up getting into the ALF, thank God, in spite of the miserable PT and his interference.

I love Joann's suggestion to tell the facility you have NO money to pay for further services. I'll betcha too that they release your mom pronto.

Best of luck!!!

OliveDup, I remember a couple years ago when I broke my arm falling in my office parking lot. My gosh, it was the most painful thing I ever encountered. My arm was in a sling for 2 to 3 weeks [no more plaster casts for such breaks] and my arm muscles froze.

Thankfully across the hall from my office was a sport's doctor so he helped me straighten out my arm. Due to the break I had the physical ability of a 3 year old child since it was my primary arm that broke. My handwriting was that of a 3 year old, so was my eating trying to manage a fork with my left hand, what a mess.

Getting dress was a major challenge, especially putting on a bra, and tying shoes. Had to type one handed, oh well, that's the norm with some people.

Thank goodness for on-line grocery shopping, otherwise all meals would be based on what was on the middle shelf at the grocery store !!

It took me 3 months of going 3 times a week for therapy. Thus, recouping from such an injury can take a lot of time. Plus one's mind is in a tizzy afraid falling will happen again.

For your Mom, the facility said that she is a little tentative, thus that tells me she isn't quite ready to go home. Do check with the social worker at the nursing facility to see what can be done regarding paying for the extra days.

You state that "at day 31 of her stay, her secondary insurance stopped paying and now she is paying $167 per day co pay." Why did the Secondary Insurance stop paying? Isn't it a Medicare Supplemental Insurance that pays for what Medicare does not pay for? 

My 87 year old Mom did NOT have to pay for anything when she was in Skilled Rehab because her BCBS Medicare Supplemental Insurance covered what was not paid by Medicare. 

You and your Mom need to contact the Secondary Insurance Company and find out WHY they quit paying for her care and why she is having to pay a Co-Pay?  What part of her care did the insurance company quit paying for?  Sometimes nursing homes make mistakes on the forms that they have to send to Medicare and to the Medicare Supplemental Insurances which can result in nonpayment or a lower payment from Medicare or the insurance company.

Also, have a meeting with the people who make the decision as to whether your Mom can go home or not.  Ask for the specific reason(s) why your Mom cannot go home.  What do they mean when they say that “she has to be absolutely perfect in the evaluations for her to be cleared”?  Is it something as simple as the need for a permanent grab bar in the tub or shower? Does she need rails on the toilet? Do the dishes in the kitchen cupboard need to be rearranged so that she can reach them easier? Is the microwave TOO high for her to use safely?  Does she need better handrails on the steps into her house or inside her house? Do the people who make the decision think that there are TOO many steps into your Mom’s house and are afraid that she might fall trying to walk up or down the outside steps?  Are there area rugs that need to be removed so that your Mom does not trip over them?  Does your Mom have an “Alert button” in her house that she can push in case she falls again or does not feel well?  Find out what is keeping “THEM” from releasing your Mom to LIVE BY HERSELF again.

WHO at the nursing facility mentioned calling Adult Protective Services if your Mom leaves AMA?  Did they give a reason why they might call APS other than “your Mom left the nursing home and you took her to her home AMA”? What are their concerns? 

You need to ask more questions and find out exactly WHY "THEY" will not let your Mom go home.  It might be because she is 90 years old and you live 2 hours away.  You won't know unless you ask them.  Good Luck.

Tell them in writing that mom has no money and will never be able to pay the bill.

They will reassess her and order in home PT and OT, Medicare pays for these services. If she leaves AMA they will most likely resist paying.

I was told that my dad needed 3 to 4 more weeks of SNF but the next day his insurance said they would not pay anymore and overnight he progressed enough to go home. Amazing!

Please make sure she really is ready and able to go home. Try to get the insurance company to do an exception pay if she's not ready. Cheaper for them in the long haul. Then everyone can be assured that she will continue to do well.

You need boots on the ground there to see your mother in person. Spend a few days visiting her while she does PT, etc.
But don’t let her sign out AMA for reasons stated in previous posts.
There is a reason they aren’t discharging her and I don’t think it’s fraud. There are probably other folks needing rehab in the wings.
IMO you should visit ASAP & assess for yourself.
Is her home set up to assure she can manage to care for herself? Does she have a Lifeline device to press if she falls again? Her level of care may have changed and her home may need modifications.

I have been thinking about this. If the telling them there is no money doesn't work call Medicare. Explain that Mom has no money for further PT. You have been told she is progressing well and she would like to leave. Medicare tells them whether Mom can stay based on the reports sent to them from therapy. They will review her progress and they can tell rehab to release her to PT at home. Once Medicare won't pay and you can't pay, she will be realeased. She may do better at home.

I was told my Mom, even with a walker, would need assistance at all times when she returned to the AL. I questioned it because she was only in the hospital, for a UTI, from Tues to Friday. Before that she was walking all over the AL with a walker. When she returned to the AL within 24 hrs she was again walking all over the place.

I really don't see how they can get better when they do PT, OT for maybe a couple of hours a day and then sit them in a wheelchair the rest of the time.

I just went through the same thing with my Mom. She was in a skilled nursing facility for rehab but when I went in to see the place, they had patients in a hallway so small to do PT. I told them she wouldn't get the PT she needed if she couldn't walk around seeing that was the main reason for PT. I called the family doctor who called the doctor there and said he was taking control of her care. The doctor at the facility said he would not sign off on her release but I still was able to take her home even though the orders said AMA. The family doctor contacted her insurance company to explain the reasoning for the discharge and they covered immediate reinstatement of home nursing and PT. Most facilities have their own doctor so they tell patients they don't need to keep appointments with their PCP but I kept having my Mom go to hers so he had a record of how she was doing the whole time. Get your Mom an appointment with her own PCP and then let the doctors work it out. The other thing is, if she is released AMA, the facility cannot send her home with a supply of meds so make sure she has what she needs at home. It's a process but it can be done. You just need to get the doctors talking and they can work out a plan for a transition home.

Not as simple as it sounds is it. You’ve gotten all kinds of advice. My question is have you been offered to have a care conference about your mom. The social worker or director of nursing should help to arrange this you will sit down with your mom and the people involved with her rehab and discuss her case. There you should get answers in a group setting. Medicare does have its own strict rules about paying for rehab in a in patient setting. And Medigap plans don’t usually cover everythingonce medicare runs out. We ran into a lot of issues with Medicare due to my dad's multiple falls that required rehab stays too close together due to their stupid rules.
A care conference is essential.

Heres how I did it. After a week in a rehab care facility I was not impressed with the care. My mom was dressing, feeding, and making it back and forth to the bathroom without assistance. I told them that we had decided that we had enough help to care for her at home. That her personal physician had ordered visiting nurse and PT and that I was flying in a relative that was going to live with her for a few weeks. I also had a vacation week coming and I would take a week with her. I insisted on being part of the evaluation meeting and sat with the people who made this decision. They were not happy but they did what I asked. It is not AMA if you have the care in place at home for your mom. You can decide that you don't want to use a rehab and bring her home instead. $160 dollars a day can pay for in home care at least part of the day. But you have to be there to let them know that you have organized all this. They can't really say no.....

I am starting an organization in Ohio, Elderly Advocates (we are on FB). This is the kinda stuff we want to help with once established. I have personally seen how evaluations go in connection with payment in PT. If your primary doctor agrees to release her, that is not leaving against AMA. He has the final say over the PT dept. as he knows your mother best. If you feel you can get her the supplemental care at home, and she is in no danger, there is no reason she can't go home!

This is what is the real problem. The facilities taking over our loved ones, them deciding what is best and making the decisions. Many times it is money motivated. They will usually decline once the PT is over. I know of someone 91 and living home alone. They try to make a big deal out of normal older aging things. They try to diagnose them with dementia, when it is just normal forgetfulness of old aging.

They love to threaten families. Im sure you would not want her to go home if you felt she was not safe. Help her keep her independence as long as possible. As far as being low income, call your local Office on Aging. They can get you connected with State Assistance Programs that can have meals deliever, aids out to help, and many other servcies.

If you get the doctor and Office on Aging to assist, their threats will mean nothing.

Do what is best for your mom always!

Prayers to you and your mom

I believe that she is better off staying at the facility. You live 2 hours away and she is 90 years old. She is still prone to falling again. She has a heart condition so the healthcare person that cares for her can detect any problem before it becomes serious.
It would be better if you or a healthcare provider would call the state and demand that they give her back her care services. She needs it. This is the real issue. No one should be left to live alone with 167 bucks a day or 4000 a month to care for themselves. If that is not feasible then find her an ALF to go to so she can live in it. it includes everything that she will need and still give her some independence.

My mom is 83 and lives in an assisted living facility. When she falls, they generally send her by ambulance to the hospital. On one occasion, however, they did not do this; instead, they called my sister and she took her to Urgent Care to have her checked out. Urgent Care's CAT scan was down and, since she said she had hit her head when she fell (no one saw her fall), we wanted to make sure there was no fracture or bleeding on the brain. My sister then took her to the ER. At the ER, they kept her for about 8 hours. Finally, they did the CAT scan, which was normal. My sister asked that they do a urine culture because Mom has frequent UTIs and was acting confused. That's when they decided to admit her. We thought it would be just an overnight thing. We were wrong. Every day my sister or I would call the hospital to ask when she would be released. We also asked for a diagnosis. We got nothing. The attending doctor would not meet us face to face but called our cell phones while we were at the hospital to speak to us! No one could tell us why she was still being held. They did nothing for her but tell her to stay in bed all week and give her the meds she had been taking all along. She felt fine and told them so often. Finally, I had a showdown with the nursing supervisor. I said "tell me what her diagnosis is and WHY she is still here." The nurse hemmed and hawed. I asked to speak to the doctor and - once again - he called on my cell phone. He was all wishy washy about why she was there. I was ready to take her out AMA, but was told she could not return to her assisted living facility if we did that. Then, I said I was getting a lawyer. That was the magic phrase. In less than 10 minutes, a physical therapy specialist was coming down to evaluate her to see if she could walk. Well, Mom got out of bed and fairly raced down the hall way. The PT specialist said "there's no reason she can't go back to her facility - why is she still here?" We were out of there 30 minutes later. Found out afterward that elderly patients on Medicare are kept a certain number of days so that the hospital can collect payment. There had never been a physical reason for her to be admitted or kept there for a week. This was a state teaching hospital too. Mom has never gone back there - she is afraid if she does, she'll never be allowed to leave.

I wonder if their assessment would change if it is made clear to them that there is no money to pay what the supplemental has been. She is unable to pick up the balance. In my experience the rehab facility was really good about warning us ahead of time about when various coverage would run out and when they weren't going to be able to find a qualified reason to keep her (even though it exited, just not by Medicare standards at that time) so would need to either send her home or to a NH (next step down from where she was) similar to what the hospital did when it was time for her to leave there and go to rehab. But they specifically warned us enough ahead of time so we could make decisions, get plans in place before it happened. So unless they are giving your mom reasons she isn't disclosing to you (are you in direct communication with people at the facility, are they discussing her condition and plans with you and or including you in family update/planning meetings?) I think you are right to be highly suspicious of their goals here.

If making it very clear that the only payment they will be getting is what they get from her insurance (she sounds well insured so they aren't suffering) because she and the family don't have money to supplement with doesn't work I would consult with her primary and or specialist and even the hospital or doctor that signed the orders sending her there about what they can or can't do in this case. It may differ from state to state so these are the people who will either know or know where to send you to get the truth about options as well as raising suspicion about this facilities practices. If they want to keep her or feel it's that necessary they will find a way to get the expense approved or keep her anyway beaus they truly have a responsibility to do so. Funny our problem was as much as the facility agreed mom need the intensive speech therapy and we needed the help, they couldn't find ways to get it approved by Medicare so she was being sent home before she was really ready. They would have approved and sent her to a NH but we knew that was going to hurt more than help her at that point (much like your mom her mobility was great, far advanced in comparison to other in a NH) so we chose to take her home with us, she wasn't able to be on her own yet.

Iablover64, the hospital must have been lying to Medicare because they determine how long a patient stays according to the information you are given. When you can't get answers always call Medicare and/or the supplimental. They can check things out for you. They don't want to pay anymore then they have to.

Has a plan for safe discharge been discussed? I agree with the advice that you need to get to her facility and participate in a care management meeting. It may be that the NH doesn't feel your mom has enough support at home. Family participation in discharge planning may help.

Our situation was they didn’t want responsibility because as soon as I mentioned I’d start looking for AL, miraculously she was discharged to the AL. Fail risks are very common and seem to be the fear that keeps folks in extremely expensive situations. My mom wants to go home. Her hip replacement and PT,OT say she’s great, but we’ve been terrified of the exact threat y’all heard, APS! Is this common thing?

My mom 84 lived alone, also. Wants to manage her own meds (adds to fall risk?) my feelings are if she wants to go home she should. I can get an electronic med dispenser which she will refuse to use.

Maybe the solution can be met in the middle for awhile. The skilled nursing discharges her and instead of the $167 a day, $75 for 3 hours of a caregiver or whatever it costs in your town. Mine it is $25 an hour yet my father pays $17 an hour in Miami,FL. If she seems to be doing well after a couple of weeks it might eliminate concerns and establish your mom's safety. It could also allow you to know from the caregiver your mom's performance at home so you feel safer too.
Take Care

I'm thinking the facility does not want to discharge your mother because she is the best patient they have. Feeds herself, dresses herself, walks, etc. They like the fact that she doesn't need nursing care. Also....every facility has a bulletin board somewhere with info on how to reach an omsbudsman. Check this out.

This is the only reason they give? "...each time they say she is just a little tentative and therefore they won't clear her to go home."??? That seems a little shady. Who at 90 wouldn't be a little tentative at times? Better to be cautious than reckless!

At the conclusion of a very recent ER visit, they did they usual - can she walk with walker, etc... Mom has dementia, has been using a walker for almost a year, has been in MC for almost 2 years. She was there to figure out why she is having extreme leg pain, enough that she has difficulty dressing, showering, walking and sometimes refuses meals because she is in so much pain. That said, she was NOT able to stand for them, not even long enough for me to pull up her panties and pants. She could/would not walk with the walker even with two staff members by her side, yet they discharged her. Test results revealed nothing. Granted she is in a facility, but still, her condition was really poor at that point (we were not looking to get her into rehab or SNF, just trying to determine the cause of this pain), yet they let her go back to the MC facility. Looking back, she was probably upper 80's when she tore her rotator cuff. She had surgery and was released home to her own place the same day (lived alone then, no dementia) and PT was brought in to help her recuperate. How bad was mom's break that she even needed to be placed there? Why not treat the arm and release to home, with services brought in? If she was able, within a month, to do all you say, I would question even why she was there to begin with!

So, given that your mom can ambulate, care for herself, etc, I would have serious concerns about what their reasons are for refusing to sign her out. Yes, she should have some kind of support system at home, at least for a while, to ensure she is doing well and can manage on her own again. One option, can you have her released to move in with you, temporarily, so that she has more support and you can monitor everything for a while before moving her back home?

As others have suggested, I would demand information and reasons for keeping her. If all they can say is she is tentative about doing something, that really isn't a reason to keep someone in rehab in my opinion. Telling them she cannot pay for the stay might help push this along (they CANNOT force YOU to pay.) It cannot hurt to ask Medicare or any supplemental insurance why payments are denied (I thought Medicare covered 120 days???) PCP might be able to intervene as well. Worst case, threaten with legal intervention! From your description, it sounds like she is being held against her will and they just want the money (although there are often waiting lists for rehab, perhaps they have no one waiting and want to keep their beds full!!) Would her doctor be willing to come to the facility and "test" mom himself? If he can see how well she is doing he may be able to override (one would think PCP and family have more authority than some random facility - and again, why did she need to be in this place to begin with?)

I think as long as your mom is making adequate progress, medicare will continue to cover. Your mom lives alone and although improving, may not be strong enough to live independently 24/7. I guess a good test for you would be to answer this question. If your mother didn't have to pay $167 per day, would you be pushing for discharge yet? You need to have a care plan meeting so that the care team can explain what your mom's goals are for discharge. In terms of the growing bill, as long as she pays a little each month, she can take as long as she needs. If her income is very low, she may be eligible for Medicaid. If she is, Medicaid will pay that outstanding bill. In the application process, you need to notify them of these bills. If she qualifies for Medicaid, she will likely qualify for other help in the home as well. My best advice to you would be to request a care plan meeting, talk to her social worker in facility, talk to someone in the business office and speak to your local/county senior council or SHINE rep to learn what your mom qualifies for in addition to meals on wheels. In my state, there is a program, Frail Elder Waiver, that allows a person to have more than Medicaid allows but provides assistance in daily living that allows an elderly person to remain in their home. This terrible thing of breaking her arm, may in the end help link your mom up with more care programs to improve and prolong her ability to remain in her home. You can help her with this!

The problem here is she has no money for the extra days. She has to make the office aware of this. They will either discharge her or have her file for Medicaid help. The balance of her therapy can be done by homecare which Medicare should pay for. Even if she owes something it will be far less than $160 a day.

Well----Medicare is the highest reimbursement rate for skilled nursing care. So, facilities tend to want to keep residents using Medicare payment as long as possible. They even try "hard ball" tactics with threatening to call Adult Protective Services. The potential problem with leaving Against Medical Advice (AMA) is that the doctor she has at the nursing home won't order any services or prescribe needed medications for the person when they leave. However, your mom's primary doctor, in the community, is willing to do such. If you feel comfortable with your mom leaving, your mom's doctor is ok with it and your mom wants to leave, there shouldn't be a problem. Your mom can receive some more therapy while she is at at home and home bound.

If you are afraid Medicare will not pay for her nursing home bill if she leaves AMA, I have previously researched this with Centers for Medicare and Medicaid Services (CMS) and that is not true. It is another falsehood nursing homes tell families and residents.

Your mom may fall at home. She may fall in the nursing home. But, she will likely get stronger at home with therapy where she has to do more for herself---but more importantly she will be happier at home.

YOU MIGHT WANT TO CONSIDER HAVING YOUR MOTHER SEE ANOTHER DOCTO FOR A SECOND OPINION JUST TO REASSURE YOURSELF. THE SUGGESTION ABOUT TALKING WITH THE LOCAL CEPT. OF AGING IS ALSO A GOOD ONE. YOU CAN ALSO TALK WITH MEDICARE AND YOUR MOM'S SECONDARY INSURANCE AS WELL TO SEE WHY THEY ARE DOING WHATEVER THEY ARE DOING. IT MAY ALSO BE APPROPRIATE TO HIRE SOMEONE TO PROVIDE DAILY ASSISTANCE WHEN YOUR MOM DOES COME HOME. YOU MIGHT EVEN TOUCH BASE WITH AN ELDER CARE ATTORNEY ESPECIALLY IF YOUR MOM DOES NOT HAVE WILL, POA FOR FINANCES AND HEALTH CARE MATTERS. [EVEN IF SHE DOES IT MAY BE WORTH UPDATING THEM ESPECIALLY IF THEY ARE OLD.]

It is my understanding that the M.D. is in charge of giving the orders for discharge.
It is the role of the discharge nurse to arrange for home care.
Follow the previous good advice.
I would like to add that you may have a doctor in charge sitting on the fence.
On one hand, he/she is saying your Mom can receive the needed care at home.
On the other hand, he is listening to staff say different.
On his third hand, if there is a real medical necessity for her to stay, doctor should be writing for an extended stay appealing the insurance decision, seeking medical approval for a longer stay (longer than Medicare has allowed for what is usual, customary, and reasonable for Mom's condition UCR).

This means, there is not enough information yet. When no one is running the show, exploitation runs rampant. Especially during the holidays, neglect to follow through.

If she is strong and competent, that is the priority. Do not abdicate your common sense to any 3rd party - even if they claim to be "experts." The idea that APS would be activated is ridiculous. They would have to prove that she is incompetent and presents a substantial and immediate risk to herself by going home. Honor her by supporting her decision to go home and not drain her finances. My 93 year old father also insisted on going home from a skilled nursing facility after benefits ran out. They also strongly insisted that he could not get by with just home PT and OT visits. However, we reluctantly honored his decision and he happily spent his final 14 months at home and saved his remaining nest egg for our mother instead of being paid to the skilled nursing facility. We have always been grateful for that decision.

I think your biggest problem here is your secondary insurance...My 93yo mother has AARP supplemental insurance, which is united health care insurance but she has plan F. My mother has already been in there close to 90 days and we have not paid anything and we won’t have to. My problem is going to come at 101 days, that is why I am trying to contact the SNF to see what my options are. I think you need to look at a different plan that your insurance company offers.
https://www.medicare.gov/coverage/skilled-nursing-facility-snf-care

Call her insurance and find out if she leaves AMA will they cover!! Don't leave an important decision to hearsay, innuendo, and gossip. I wondered about this and called both my insurance companies and my husband's insurance companies. Turns out, they will pay if he had been admitted.

I did this because several years ago the hospital was going to put my husband in a skilled nursing facility to teach him to walk. To make a long story short, he had been walking fine when they admitted him for a heart problem. They had kept this 83 year man in one position for a week. No turning, no moving around. The last day they had a Physical Therapist get him up and he had a hard time walking. I told them it wasn't going to happen. All he needed was to get up. They were getting the AMA paperwork ready when (Wow) the regular release papers showed up. In an hour he was walking just fine. All he needed was to move around a little bit. Of course I am leaving out my "talks" with the Doctor and a lot of other garbage.

I would insist on a meeting with the Doctor in charge, Pt & OT Techs and facilty manager together. State her case ,ask what more is expected of this remarkable 90 year old woman.