Help! Mom broke her hip and skilled nursing says Medicare will not pay.

After coming here I continued doing researching and learned more about the Medicare rules. The odd thing is I don't ever remember calling you stupid or dump. Can you show an actual example of that? Even though I have point out comments that were out and out wrong, I don't even show where I did that to your comments. I just respond with facts.

No one is turning down therapy. But I guess it is subjective. Ones person trying their best might be another person idea of turning down therapy. In one person's mind maybe if the patient cannot stand and take X steps that is turning down therapy.

I talked to a family member in another state who is an administrator at a large facility that does skilled nursing, nursing home, assisted living and the like and she said they care about their patients and never discharge a patient for the reasons we are being given so again it all is subjective.

In my opinion the therapy needs to be biased on the patients past history and ability. So if they cannot stand and take steps you have them ride the bike and do other exercises to build up strength so you can then take steps.

"To go back to her assisted living, she to be able to go to meals using her walker. "

Her assisted living has no such requirement and in fact most the people there are in wheelchairs and can not walk on their own. Maybe you are thinking of independent living. The only requirement for her assisted living was the person could pivot for a 1 man lift and even that is waived after you are established.

"For Medicare to pay she had to follow their instructions and make progress"

I don't know why people continue to spread this false statement about making progress even after I showed the lawsuit and the settlement agreement. The main reason I respond to this inaccurate comment is for others can know the truth. The sad part is even the facilities don't know the truth about the Medicare rules.

I actually even talked to the lawyer that was involved in the lawsuit. As shown in the links I provided Medicare has come out and stated their is NO improvement requirement.

The Center of Medicare Advocacy filed a lawsuit regarding this specific matter in the case of Jimmo v. Sebelius. The outcome of that case is there is “No” Improvement Standard required for Medicare to cover skilled nursing and physical therapy.  A doctor can order PT just for the patient to just maintain or not degrade.

I will include the links again. If people don't care about the actual facts, not sure what else I can say 
 
Pub 100-02 Medicare Benefit Policy again stating the changes regarding Medicare Policy due to that lawsuit.
 
http://www.medicareadvocacy.org/wp-content/uploads/2018/08/Checklist.pdf
 
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R179BP.pdf

rocketjcat,

“do they accept residents in wheelchairs and do they accommodate 2-assist residents?”

They do which is why we choose that place, but you are right it really is arbitrary and up to them to decide. I meet with the executive director when I was in town and when mom first moved to the assisted living place and hammered this point again and again. I was clear we do not want mom to go into a nursing home and if anything happened do they take the patient back after surgery or skilled nursing. They told me they do everything in their power to keep a resident once they are established. For example they cannot take a 2 person lift resident as a new resident but will keep a resident if they digress into a 2 person lift.

I see people there that are in wheelchairs who cannot do anything. Most residents there are in wheelchairs. The do charge more based on level of care needed. My mom was at level 3 their highest level of care. But they can also say if you cannot pivot we will not take you. It really is up to the executive director. 

“I found that dealing with the rehab progress after Moms falls and surgeries to be one of the most stressful and frustrating parts of this this journey.”

You are not kidding. Very little empathy out there or understanding on how everyone is different. Just because another person or their parent was up and running in a week has nothing to do with this situation. We are trying everything including paying for and hiring some of her previous caregivers to come in and encourage her to eat and exercise. I hope others don’t have to experience this so they know what it is like.

Plus there are just so many other issues going on the same time. Like her pain medicines were affecting her mental state and making it extremely hard to communicate so the doctor tried to switch her and that made a huge difference, but then she is in more pain. Nothing is easy!!!!

“She went into long term care and the PT started up again. Same cycle but she did much better there. I think the hospital fuzzies we’re finally wearing off”

I have a story along those lines. She had fallen before and went into skilled nursing and did PT and when she came out I saw no evidence of improvement what so ever. She could not get up or sit on her own moreless walk with her walker. She then started outpatient rehab and Wam Bam she was back walking with her walker in a matter days. I personally think skilled nursing treats patients terribly. This is a true story. I go to skilled nursing and they have all these patients just lined up in front of the desk in their wheelchair. They looked so miserable and my mom was there and super upset that she was just left there for 2 hours. So I ask the person behind the desk why is mom just sitting out here for 2 hours and she say, “They put the patients out there so they can keep an eye on them and they are waiting for PT or OT and they are happy”. Happy!!!!! you must be kidding. They were all miserable. It is beyond SAD!!

Shane1124,

“What was her level of activity prior to surgery? “

There is a long history to explain so I will keep in brief. Mom walks with a walker but fell and was in outpatient rehab at assisted living. She had just gotten back to the point where she could walk with her walker again (short distances) when she fell and broke her hip in the elevator. So her walking ability was never great to begin with.

“They have written standards with goals that must be met for post op hip patients “

I have to disagree with you. The PT should not be setting the standard, but in my opinion the Doctor, preferable one that knows the patient history should. This is one of the problems to me that you have a PT who knows nothing about the patient’s history setting what they think her standard should be.

That lawsuit was clear if a person needs PT just to maintain or not go backwards Medicare will cover it. You can disagree with the lawsuit but I actually agree with it. That is why we are going to talk to the surgeon that ordered the PT to see if we can get realistic goals. 

I agree it is important for the patent to move, but if they cannot take a step or enough step right away then moving on the bike or other exercise are just as important. The rehab should be based on getting her back or what is reasonable back to her pre surgery condition and she was not running laps before surgery as I explained.

Tothill,

I think everyone is genetically different. There are folks over 100 that play golf. You are lucky that your father is in such great shape that he can work out with weights, but not every person in their 80s are so fortunate. I think mom is doing the best she can. Prior to this she was in assisted living and did their daily exercise, but she is not in great health and shape. Yes she could have done more to stay in shape and work out when she was younger, but that is history. She has had back injuries and other issues in the past.

I just think the whole Medicare skilled nursing system is a disgrace. You are fighting with 2 large bureaucracy and no one advocates for the patient. Instead of having a doctor that knows your history you are under some Doctor paid for and hired by skilled nursing making decisions for you, that can not even spend 5 minutes talking to siblings. I cannot imagine how one could device a worse system.

Sorry. Was typing in bed at 4AM. Anyway, ask to speak directly with her doctor and tell him/her what’s going on with your Mom. A new plan for Mom needs to be formulated because this one isn’t working. I feel bad for your poor mother. She’s trying and they aren’t setting her up for success. Come back and let us know how it’s going for her.

Bilsko,
Communication is extremely important when a loved one is doing therapy.  Please do not get upset and angry (or confrontational) when you or your sister are talking to the therapy staff.  It will only make things worse.  Be respectful but firm. 

Contact the physical therapists at the facility and explain the situation to them.  Ask them to explain the guidelines that they must follow for your Mother to continue to qualify for Medicare.  I know from experience that the guidelines are very complicated and sometimes difficult to understand or to apply properly to the resident.  In regards to standing and walking the resident needs to increase the number of steps that she/he takes each day that they have therapy otherwise they might not be considered as "progressing".  Since your Mother has only taken one (1) step and has not progressed to taking more than that, then Medicare can consider her as "not progressing" and terminate therapy. 

Many "Skilled Nursing Care" facilities are also "Long Term Care" facilities.  When Medicare coverage ends, the resident moves from the "Medicare Unit" to a "Long Term Care Unit".  Is your Mother in a "Skilled Nursing Care ONLY" facility that has no other nursing care units or floors where long term residents live?    If your Mother has to move to another long term care facility, make sure that it is one that offers Medicare Physical and Occupational Therapy within that building.  It may be that your Mother's hip needs more time to heal before physical therapy can be done.  Once Medicare ends, will your Mother be "private pay" or "Medicaid"?  Either way, your Mother can restart Medicare-paid Physical Therapy or Occupational Therapy when she is stronger and the pain is under control. 

Is your Mother having Occupational Therapy during the morning?  If so, ask if Physical Therapy can be done in the morning and Occupational Therapy in the afternoon.  Ask the nursing staff to lay your Mother down in bed after lunch so that she is not so worn out for any therapy in the afternoon. 

You have stated that your Mother is in pain when she stands up and takes a step.  Does your Mother use a wheel chair most of the time or does she walk to and from therapy OR to and from her room to the dining room?  If she has a wheel chair, has it been designed for her or is it one that the facility owns?  When your Mother stands up, does she use a walker--is the walker the proper height for her or is it too short or too tall?  Where is the pain when she stands up and when she attempts to walk--in her hip?  in her knee? in her low back?  Does your Mother have the same complaint when nursing staff assist her to transfer from wheel chair to bed or to toilet.  Or does the nursing staff use a "Sit-Stand" (or "Easy-Lift") mechanical transfer device with your Mother for transfers in her room?  Can your Mother stand, take a step or stand and pivot from bed to wheel chair in her room with assistance of nursing staff?  When are her pain medications scheduled?  Ideally, pain medications are given 30-45 minutes PRIOR to therapy sessions so that the maximum amount of pain medication is in the blood stream.

Ask if the doctor can order a hip x-ray (while standing) to see if your Mother's hip is healing or to see if there might be a physical cause for her pain when standing. 

Continue to ask questions and attempt to work WITH the therapists to resolve the problems that your Mother is having with therapy.  I know that it can be frustrating when someone does not do what you expect them to do, whether it is a therapist, a nursing staff member, a resident or a family member.

Have you had a chance to review any of the websites that I listed for you in another posting?  I think that they might answer some of your questions.

I’m sorry. I did not realize you were in a different city from your mother. What about a video conference or even a conference call? You can also request another therapist. My mother’s facility had 3 or 4. You can also call the director of the rehab and tell them you don’t feel your mother is getting the support she needs to make progress.