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Because of a question someone else asked about Medicare rehab, and people referencing the Jimmo settlement in their answers, that was the first I'd ever heard of that! And, I think, the first that the nursing home my mom is in had heard of it, too!


My mom is 81, has Parkinsons (no tremors, but had gait and balance problems), mild Dementia (affecting short-term memory) and kidney issues. She has been able to stay living at home independently thanks to the Medicaid Waiver which provides home health aides every day for 8 hours (split between a.m. and p.m.), weekly nurse visits who fills her electronic pill box, and a Life Alert pendant. She's been doing pretty good until recently. In mid-May she caught a cold which then turned into pneumonia. Her cognitive skills have declined and so far have not improved even though the pneumonia was gone by 5/24. She fell a couple of times or slid out of her chair (leather recliner) and wasn't able to get up on her own so EMS had to be called for lift assist. On June 7 the aide arrived at her house for her 9:00a.m. shift and found my mom on the floor in the kitchen. She had fallen at some point. She was conscious, but for some reason had never pressed her Life Alert button, so we don't know how long she was down. EMS took her to the hospital and due to the unknown time, dehydration and rhabdomyolysis they admitted as an in-patient for 4 days. So that qualified her to go to a nursing home for rehab under Medicare (instead of Medicaid). On June 11 she was discharged to the nursing home. Last Monday was her first care conference (which I attend via phone as I live 2 hours away). Today was the second one. They are not optimistic about her being able to go home as they are not seeing much improvement. She has been walking more (with a walker), but she still is quite confused and needs help with pretty much everything - dressing, bathing, toileting, figuring out how to position her body to move around people/things when walking.


But I'm thinking "she's only been here 2 weeks!". She was there 2 years ago after pneumonia (under all-Medicaid that time as she did not have the in-patient hospital stay then) for rehab and she was there for 5 weeks at that time, and she WAS able to go home then. I know 2 years is a long time, and maybe her conditions have changed to the point where it's not safe for her to live alone now, but it was like a light switch was flipped. Before she got the cold/pneumonia last month, she was FINE. And then boom - major confusion issues that haven't yet seemed to start to go away. But I feel like she could improve given more time before pressing the "Easy Button" and saying she needs to stay at the nursing home forever now.


So at today's care conference they gave me the 2-days notice required to let us know that Friday would be her last Medicare-covered day, and as of next Monday she'll be there on 100% Medicaid. I think she'll still get therapy, but not at the same level as what she's had the past 2 weeks.


I brought up the Jimmo settlement and read right to them about maintenance nursing and therapy, and preventing or slowing further deterioration, and how she can't be denied based on the absence of potential for improvement, etc., and no one sitting around that table seemed to know what the heck I was talking about. I told them I was going to appeal the decision and they said they'd fax me the papers.


So my question is....how involved is the appeal? Do I need doctor's notes, etc.? Do I just cite the Jimmo settlement and explain how it should apply to my mom? I need to get my ducks in a row to do this appeal process and try to keep her under the Medicare coverage for SNF/rehab, as least another month or so, until I am more convinced that she's not going to recover to the point where she'll be able to go home.

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So what happened?
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Reply to needtowashhair
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Since you are from Michigan based on previous answers. Medicaid Waiver Services are a joke. They allow people who should be placed to remain in their homes WAY past the point they should safely live there.

So before she got the Lifeline, she forgot to take her pills for the week. So if the nurse is there weekly since the machines hold 60 doses, she probably has a complex regimine. If you have been around the machine, after 15 minutes a siren goes off for an hour...loud and obnoxious. After an hour, meds are locked (by law, the aides are not allowed to open the dispenser to get them...remind to take only). Have you asked for the dispense log or has that annoying person from Massachusetts called you yet over the pills.

So she falls, did they give her the necklace or bracelet...with Parkinsons, the bracelet works better. So she fell at night and laid on the floor. I do not understand how anyone safety would not be a consideration for permanent placement since Michigan will not cover overnights.

Your maxed out in terms of waiver hours and services. If more is needed, they will place her or you will need a backup plan.

My answer is a little harsh but I have already been in the Michigan Waiver shitshow and it is not fun. I have dealt with the fallout more times than I care to count over rehab and placement versus going home. I wouldnt fight it.
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Reply to tacy022
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MAB2018 Jun 27, 2019
The machine she has has 28 compartments. She takes her meds 2x a day, at 9:15 a.m. and 5:15 p.m. So it fits 2 weeks' worth of doses. The aides ARE allowed to remove the pills from the machine and give them to her - she does not have to do that herself. The aides are just not allowed to handle her meds directly from the prescription bottles. The nurse takes them from the Rx bottles and puts them in the machine. When the machine advances to the next programmed time, it alarms right then and the alarm remains on for 30 minutes or until the compartment is opened. The aide removes the pills from the box, puts them in a Dixie cup and gives them to her with some water.

Right before she went into the hospital for her 4-day in-patient stay, her hours for the aides were just increased to 8/day. But that hadn't been implemented yet. The person at the Area Agency on Agency who oversees her Waiver did tell me that she wouldn't be able to get any more than the 8 hours though.
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Try this and see if it helps.
Let us know how it goes.

https://www.medicareinteractive.org/get-answers/medicare-denials-and-appeals/original-medicare-appeals/appealing-a-reduction-in-skilled-nursing-facility-or-home-health-care
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Reply to 97yroldmom
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I don't know about the appeal process, but do know that it can take quite a while to recuperate from pneumonia, even after rthe acutre phase has passed. Parkinson's symptoms can get a lot worse during and after any kind of situation that stesses the body--infection, surgery. My husband has Parkinson's, not yet severe and he's younger than your mother, but when he had pneumonia he really regressed. He had difficulty moving in bed, walking, etc. which he'd been doing fine with previusly. It took well over a month after he was "cured" of the pneumonia to get back to his previous baseline, [particularly his endruance. I think the rehab place definitely needs to give your mother more time and continue with the therapies (physical, occupational).
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Reply to newbiewife
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MAB2018 Jun 27, 2019
Thank you newbiewife. That's what I think too! I was reading it can take 6-8 weeks for an elderly person to fully recover from pneumonia....then add her other problems on top of just her age. I think they're pulling the trigger too fast also.
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I would be concerned that she didn't have the mental capacity to push her alert button.

Not trying to be rude, but she wasn't fine or she would not qualify for in home aides everyday.

When was the last time you spent time with your mom? 2 years is a long time and as we age things progress differently.

Have they tested her for UTI? That could account for her confusion and if she was treated with antibiotics for her cold, that could have thrown her system out of wack and made her vulnerable to UTI.

I hope that she gets the care she needs.
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Reply to Isthisrealyreal
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MAB2018 Jun 26, 2019
I see her at least once a month. I take her to all her doctor's appts. Regular doctor. Nephrologist. Eye Doctor. Prolia and Procrit shots.

Well when I saw "fine" mean that taking into account her medical problems. She was alert, able to walk with her walker, hold a conversation, etc. The confusion she has had since she got the cold/pneumonia last month has not left yet, and it's been about 4 weeks since she was cleared of the pneumonia.

No UTI. She did get a 5-day run of Z-pack antibiotic after being diagnosed with pneumonia on 5/24. By 5/31 when she went back to the ER because she still didn't feel good, they took chest xrays again and said the pneumonia was gone.
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