My mother is still in the hospital. They are arranging for skilled nursing for her IV antibiotics. She has pneumonia and a suspected osteomyelitis in her spine. They consulted an infectious disease doctor and spine doctor. They said it’s not quite clear, but it’s so dangerous they just treat as if it’s an infection vs inflammation. She’s also got a whole lot of degenerative stuff, and some new severe stenosis at L4L5, which is where they think the infection is.
After, I plainly told them her house is hoarded and she can’t go there with a PICC line. Her confusion has increased and remained persistent. She always gets hospital delirium, but she is usually more cleared up by this point. She also has COPD. Two days ago, they became worried about her mental status and ordered an arterial blood gas checking for CO2 retention. The lab flagged several levels as abnormal. But yet the physicians note stated "no CO2 retention." They also ordered another chest CT, which showed "concern for progressive pneumonia and new small pleural effusions" that were not seen there on the prior day. The physician's note did not even comment about the CT and he was the one who had ordered it the day before. She remains oxygen dependent. The day they ordered the CT, she had dropped to 82 on room air when PT walked her. Her O2 levels are fine on just a little bit 2 L.
They decided polypharmacy was related to her confusion, so they reduced and rescheduled some of her medications. But she still has confusion. Yesterday, I noticed her hemoglobin had dropped to 8.9. It’s been trending lower every day. She had been on a lot of IV fluids, which could’ve caused a hemodilution, but yesterday she was off continuous IV fluids.
We stopped by her house and did some cleaning on the horrible chance that she ends up back there. I had a very frank talk with the social worker and the nurse. I said I absolutely cannot deal with her in that house, especially in this condition. The hospital social worker told me that she still has the option to refuse further care at skilled nursing. She can refuse once her IV antibiotics are done. I asked her what happens if I refuse to pick her up from skilled nursing? She told me that they can still put her in a Uber and send her home. And then at that point all I can do is call APS.
She also told me that Medicare will only pay 100% for the 20 days. Even though she needs about five more weeks of IV meds, they will not pay fully days for that saying that she could be having that at home. But yet she can’t, cause her home is hoarded and there’s no one there to help her.
As soon as the move to the SNF is made, I plan to contact the elder lawyer we’ve used before and get a grip on how to do a Medicaid spend-down. She only has about $20,000 to her name, including her IRA. As of yesterday, she could not do four of six ADLs. Plus, there's her mental confusion. So I guess it’s wait and see what happens after she’s in rehab.
Does anyone have experience with their elder never clearing up from hospital delirium? This is the third or fourth time she’s had it.
See that elder lawyer. I think ur getting the run around.
Sounds like this person just doesn't want to do their job, so you may have to get down right ugly with them to get your point across, and to get your mom the care she needs.
And like JoAnn said below, use moms money to pay for the facility and when it's gone she can apply for Medicaid.
This is now a "no brainer" that mom belongs in a care facility, and until you start standing strong and insisting that be done, the hospital system will continue to give you the run around. So quit falling for their BS, and make sure your mom gets placed.
On the latter, Medicare* as health insurance will pay for NH/SNF if discharged to rehab from a 3+ days hospitalization. Usually rehab in NH that is “skilled nursing & rehabilitation”. (fwiw are rehab only facilities but tend to be abt intensive specific care, like TBI traumatic brain injury). Medicare* rehab benefit cover 100% for 20/21 days then up to 100 days @ 50%. Other 50% often covered by their gap/ supplemental health insurance. HOWEVER rehab benefits are based on progress the patient is making during rehab stay. Progress is linked to discharge codes in the care plan from the hospital. Like rehab from hip surgery abt 5 weeks, so Medicare* pays 100% first 20/21 days then next 2 weeks paid by their supplemental health insurance (hopefully) or private pay. BUT they have to be - absolutely have to be - progressing in rehab for insurance to pay. If they won’t or can’t, then discharged from rehab pretty quickly.
Sometimes & less common, a hospitalized patient is discharged for ongoing care and not rehabilitation. That their care plan does not lend itself to being able to go through rehab to be somewhat back to where they were before whatever befell them to go into the hospital. This coverage totally dependent on Medicare & other health insurance policy. I’d be concerned that this maybe is how she gets discharged. Try to find this out as it’s different path for coverage.
RE Medicare*: If mom is on Original Medicare how they pay is pretty straightforward. But her 2ndary / gap / supplemental health insurance can vary & wildly. If on Medicaid for her gap, Medicaid will cover 50%. BUT if on a Medicare Advantage Plan, they tend to be beyond conservative for coverage. Likely be completely out of network and atop that very limited in days covered for a NH with rehab.
So…What is her health insurance? As mom is currently hospitalized, her health insurance is beyond mucho importante as to what coverage she has for her next placement.
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So on the discharge to Uber nonsense, both hospitals and SNF are required - under Federal regulations tied to their accepting Medicare -to ensure that a discharge can provide for a “continuum of care” that is appropriate for the patients care plan. For hospital's, it means the pt gets sent to a skilled nursing facility OR if sent home that there is home health or family who are fully able to do the care plan and that the home is safe & secure for the elder. Your mom’s home as described is an “unsafe discharge environment”. There is no family or paid for healthcare to be there for 24/7 oversight needed, so again it’s an unsafe discharge for her to be sent home. You have to - HAVE TO - make this clear to anyone you speak with at the hospital. There are other posts on UNSAFE DISCHARGE; go up to the “Q” search bar on top right of this page to find ideas on how to handle this. LSS the hospital has to find a facility to take her.
For NH wanting to get rid of a pt, it means they find a reason to contact EMS & send a resident via EMS to the ER/ED. So NH/SNF resident then becomes the problem of the ER/ED & hospital. Old NH will refuse a return using reason that they cannot meet the level of care the resident needs. It’s a legit CYA excuse a NH/SNF can use with the added plus that this move totally ensures the required “continuum of care” is there as it’s from a NH/SNF to a hospital, which is a skilled care facility.
I think that SW is either clueless, poorly trained OR this hospital takes the approach to default to pressuring the POA & family to take the patient home as that removes the hospitals responsibility entirely. You and the rest of your fam have to - again HAVE TO - make it clear that isn’t going to happen.
A ?, has anyone mentioned LTACH? I’ll do another post on this….
On the off chance, the hospital SW maybe/should be able to help with the Medicaid application.
LTACH admissions are usually done by the hospitalist in charge of the patient. Neither you or I can enter a LTACH directly. It is strictly by referral. Often the LTACH is a building adjacent to the hospital connected by a sky bridge or can be its own floor or ward in a hospital. It has its own staffing. It’s usually a 21 day admission cycle.
Kindred Hospitals (or whatever they are called now, they got bought out) are LTACHs. LTACH tend to be in bigger cities and by a teaching hospital.
I mention LTACH bc if your moms care plan is very involved, a lot of NH flat won’t want this type of resident. They will review her discharge report and will do a hard pass. The discharge planner at the hospital will have to cast a wider net to find a NH somewhere who will take her or will intensify its efforts to have the POA / family come and get their parent from the hospital. Whether or not in home care by family is realistic & truly suitable doesn’t matter. Once the parent exits the hospital with family, it’s all their problem to work out. Having your mom move to a LTACH might - just might - be an interim solution.
My MIL went to an LTACH. She had been in a NH as Medicaid Pending; got pneumonia and treated at the NH; stabilized; then few weeks later got pneumonia again but way more ill this time; EMS called and she’s admitted to the hospital; did not get better, got sepsis; she moved from the hospital to the adjacent LTACH; septic and with cascading organ failure; died not quite a month after entering LTACH. Medicare paid for all. The LTACH did a recode on her diagnosis once there so coverage got extended past the standard 21 day coverage. The staff at the LTACH were phenomenal.
i’m not a RN but just in reading your post, moms care seems very involved. It may be worthwhile to ask if they can do a referral for an LTACH for her.
If that is not possible, then I’m 100% with JoAnn to use moms 20K to get her into a NH that has LTC Medicaid and does “Medicaid Pending” and mom private pays till she’s “at need” financially for LTC Medicaid filing. You as her POA use those 2 or so months to get all paperwork she needs to file that LTC Medicaid application. She totally uses her assets this way as her spend down. It’s a clean clear use of her $. Imho do no trying to be creative with $ crap, just too much risk as you don’t have time as she right now at need for skilled care.
Now finding a NH that is ok to do her care plan may be challenging. Good luck and remember “unsafe discharge” is your mantra.
unfortunately, mother‘s behavior is becoming a problem. She is what they are calling sundowning. She gets agitated around two or 3 PM starts wandering and has had two falls already. They do not have the staff to watch someone like her. I think when the hospital did the discharge they did not realize that her mobility would improve as it had. She still has terrible balance, and is a terrible fall risk, but she does have strength, and her pain level with walking has decreased since she’s had the antibiotics. So when she’s upset, she’s got the strength to try and walk. The SNF mentioned we might need to get a sitter. And I am not keen to spend her money on a sitter until we have more of an understanding of the Medicaid process. Again, it sucks that all this happened on a holiday weekend. But my main mission this coming week is to get a grip on the Medicaid stuff. They mentioned they might have to send her to a facility with a locked unit. So I don’t know how that would play into our Medicaid application paying the nursing home in the interim, etc.
Without a good neuro-pych now stepping in you cannot know if this is mental illness, hospital delirium or dementia.
And there is ZERO you can do about any of the three of these.
Unless and until your mother's placement is safely IN YOUR HANDS there will BE no placement. Nothing you can do.
Again, take a few days off from all this. Your angst is likely more contributing to it than helping it.
Get her an elder lawyer and a good social worker.
I think it is against hospital rules that they send her home unsupervised and into her hoarded home with her equipment she cannot even use there. Ignore what that social worker said! The hospital may face a lawsuit and the doctors their biggest malpractice suits for treating mom dangerously in her condition, especially if she dies under their care.
https://www.agingcare.com/questions/have-i-got-a-story-for-you-mother-update-snf-admission-and-some-challenges-494378.htm?orderby=recent
However, if she is "competent" she can be sent home alone at her request. We all know what a disaster that would be.
Doctors order tests to evaluate patient condition and help guide the plan of care.
Things like x-rays, CTs, MRIs need to be evaluated by a radiologist who is the expert in reading them. Most doctors rely on the radiologist to catch the small changes. Most specialty doctors can read films in regards to areas for their expertise but will not post findings - since that is the radiologist's job.
People with chronic illness - like your mom - are more prone to developing infection and exacerbation of their illnesses when in the hospital for something else. Their body systems just not work as well or cope with stress of injury/illness as well as younger, healthier bodies. SO, I am not surprised your mom developed respiratory issues and other health issues. Doctors and hospital staff work hard to notice changes, diagnose conditions and treat those conditions. Most hospital staff work hard to prevent more issues from arising.
You are correct that labs change when people get fluids. If a person is dehydrated, then the new numbers are actually more "correct." Ask the nurse at what point are labs that are abnormal need correction - specialized medications to correct imbalances, blood administration...
Ask case manager/social services if it is possible to set your mother up for longer term treatment for iv therapy in a facility. If not, ask what all your options are. If your mother is deemed mentally competent to make her own decisions, she can choose which course of action that she wants (even those that are not in her own best interests).
Worse come to worse, if she goes home to her "hoarder's house," you can call EMS to take her back to the hospital.