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

I have told my husband that if rehab is recommended for getting my strength back after a 3 or 4 day in a hospital, I am refusing it. I was told Mom hit her plateau on a Thurs, but she wasn't released from rehab till Tuesday, why? Hospitals and Rehabs are not prisons. In both, you cannot make a person bath, take meds, etc but you can tell them they have to stay in the hospital or rehab when they don't want to! Something is wrong here.

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I was in hospital for unrelated issues and they would not release me. Said I could leave against medical advice but risk my insurance not paying. I very bluntly matter of factly informed them that I do not pay my bills therefore if they wanted to be paid it would be in their best interest to discharge me appropriately or they would risk not bieng paid. Guess who got their way? It is amazing how money talks.

Her question was asked the 23rd. Has had time to talk with thevNH about not being able to pay. Would like to know how it turned out.

Sounds like there is the potential for fraud. If you can go above their heads and talk to somebody and get some hard factual reasons that she has to stay With a definite released date, OK.If they don’t then maybe you jump the gun on them and bring in a social worker yourself and say you want your mother released and they won’t allow her to be released. You be the proactive one. you don’t need to be paying for that if she doesn’t need it. Good luck

Hopefully OP has spoken to rehab and told them Mom can't afford PT any longer. Would love to see what they did with the info.

It is typical for the therapy team to meet weekly to discuss a patients progress. If they are insisting she stay, maybe they see something that can still be improved. I would ask if u can be in the next team meeting (either by phone or in person. ). The team (as they call it) will only keep a patient if they feel they can get them to the next level. Her age should only be a factor if they think there is still work to be done to get her where she needs to be. To safely live alone. I think u have to push your way in and find out what it is they plan on making better. If it’s legit, then that will put your mind at ease and help you explain to your mom that this is in her best interest. If they’re trying to get her to a point that you know she will never reach, u (as her daughter) will be able to explain that to them too. Good luck. Trust me, I know this seems like a huge problem but it could be worse.... your mom could be making no progress at all! As the daughter, you have the right to give them your opinion though. Best of luck.

Short answer. Call Ombudsman and you health state agency. Aka department of health. They will help.

-Retired Nursing Home Adminstrator.

SNF wants her to stay long enough that she won't want to leave. They probably figure she is not competent enough to make her own decisions, so she should stay. Many NH do this. It is about the money plain and simple.

If your mother does go home, she may want to have an "alert" necklace/system. Have you got involved? If she goes home, can she have care a few hours a day/week? Yes, I'm sure the facility is worried about being sued, if anything were to happen.

Olivedup; so what else could be the reason they want her medicare insurance
Is what it sounds like!! and you just tell them you are going to be staying with your mom! and that you have private caregivers set up! not to mention neighbors, and family !! Do not say any more than that to them .and you can call the onbudsman yourself !! My daughter checked herself out of the hospital against medical advice she was16 nothing happened ...call a lawyer they talk to you free and will give you advice but if mom Can not aford it then they are wrong !! I have my aunt and mom at home .....but I NEVER EVER EVER LEAVE THEM ALONE NEVER, My neighbor lives alone and shes always alone!!after falling ! IF MOM IS WITH IT THEN its OK but just to be safe stay eith her at 1st ..good luck I dont want to say the wrong thing because i do not actually see and know except what you say and I beleive you ...but sometimes we may think our parents are ok to be alone because we may not have seen the dementia sometimes they can cover it up very well but not for long GOOD LUCK!!!

Sounds like the advice to actually talk to Medicare and the secondary insurance carrier to state your situation and see what they say.  Gossip and rumors can cause a lot of trouble and the thing is, insurance is complicated, so what one person experienced in their case, may not be the same for you in your particular circumstances.  It is one thing to refuse to pay the bill so far, and another to state that if you leave AMA, they will not cover if you have to go right back.  So actually talking to Medicare and secondary insurer should help to make things clear in your particular situation.

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.

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 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

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.

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.

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.]

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.

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.

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!

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'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.

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

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.

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.

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.

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.

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 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.