My dad recently had partial hip replacement surgery, he responded very well to the early PT/OT at the hospital, and after three days, he was transferred to a SNF for inpatient physical rehab. While it's early, we are concerned that he's not receiving the amount of PT/OT that he needs, per the prescription of the hospital case management team. We're raising our concern with the care team at the SNF, and we're also starting to think about the possibility of a facility transfer.
The tricky part, as far as I can tell, is doing this and getting his Medicare Advantage plan to cover the alternate facility. (Yes, I know that Medicare Advantage is bad, and I will be imploring my parents...again...to switch to Original Medicare at the soonest opportunity.) I'm wondering what kind of documentation and/or letters we should be preparing to raise the odds that the insurance company approves the transfer.
We are currently keeping track of the number of PT/OT hours he's getting. And I'm going to speak with the hospital case manager again later today to relay my concerns and get her advice. But I thought I'd pose the question here too, knowing this is probably a frustratingly common situation.
Often they reach a plateau, so rehab stops. Or they are noncompliant for care, so rehab stops. What others (Fawnby, Funky, LeaL) have posted regarding this is very much spot-on.
The therapists are entering his status into his health chart regularly and it goes to the insurer. I’d suggest that you speak with them on his status and what it means for his time to remain a rehab patient with his stay covered by his health insurance. If his cognition is such that he cannot follow through on his exercises, and this becomes sequential days he will have hit a plateau and rehab ends. If this is the direction his chart is going, it’s good to know so that options as to what’s next can start to get sussed out. Every day he’s in rehab gives you another day to plan out the future and all the logistics. My understanding is it’s 3 sequential days for being either noncompliant for care or at a plateau that triggers rehabs end. It could be that he needs his own family cheerleading squad to get him motivated or something else to get him motivated.
When MIL broke her hip, followed by hospitalization then impt rehab, she was a non-compliant 4 care type. While in the hospital, she was all “it hurts/I can’t and can you bring me another blanket/adjust the TV”. No amount of asking or prodding or cheerleading by her sons was going to make her be actively participating. It was not due to cognition and dementia, it was flat out “don’t tell me what to do”. She didn’t get the full first 20/21 days paid by Medicare. She segueway from being a rehab patient on health insurance to a custodial care resident who was Medicaid Pending. This was just her; she was a most difficult contrarian person and this b4 dementia started happening.
For my mom, it was different. She had rotor cuff surgery at almost 90 with outpt PT/OT. Very motivated as she wanted to be able to raise her arms to set her hair and put on her jewelry. Hey motivation is motivation whatever the reasons…. lol. She was good on following directions & working within a group by her nature. Later on when she entered a NH once backside of her 90’s, even with dementia, this was a big plus. Living in a NH is a lot like living in a dorm, so the ability of being part of a group can make a NH be a more positive environment.
I mentioned this as you and your Sister know your Dad best and if he is the type to be non-participatory for his care plan. If your mom has been there being with him for long periods of the day and she is and is all fretful and hand wringing, that probably is a deterrent. Yiu know the dynamics of your folks best.
Please realize that his being discharged from rehab does not necessarily mean he will have no more PT. There was a ruling several years ago ( Sibelius ruling) which meant that residents in a NH can to have therapy for “ maintenance” without having to have “progress”. So basically means Medicare* will pay for gait training and working a wheel for your legs or hands in the PT rooms at the NH. Technically it’s not rehab but maintenance. However once again the elder needs to be participating in this. So if they come by your dad’s room once he’s a custodial care resident and ask “Mr Heinrich do you want to go over for exercises” he has to go do this. They won’t force him but instead will go to the next room to get a resident and take them down to therapy.
*YMMV as y’all folks have Advantage Plan. So if he stays in a NH he will have to switch back to Original Medicare as it pays best for health insurance billable costs. If it’s looking like he will be filing for LTC Medicaid, I’d suggest you do a new post as it’s way complicated for Community Spouse (mom) & NH Spouse (dad) situation.
Appeals work best for those who are TBIs (traumatic brain injury) as their progress is very incremental. TBIs tend to be the type of patient who go the full up to 100 days coverage by Medicare. It’s specialized rehab. The broken hips seem to get in-pt 5 weeks tops if they were fairly fit before the hospitalization.
I went to all my LO's OT/PT with him when he was in rehab. Many couldn't/wouldn't participate, some because they had dementia and didn't understand what it was or why they were there. Others who didn't seem to have dementia didn't want to do therapy because it was painful, or they wanted to lie in bed and watch TV, or they didn't really want to get well. The staff tried - they certainly did - but often it was useless prattle to the patient. So, as you can see from what I'm relating, keeping track of hours in therapy doesn't answer the real question of, "Is he able to benefit?"
Good luck with all of it.
There were however many days when I witnessed older people being wheeled in in their wheelchairs that were just left to sit the entire hour with no one working with them only to be returned to their rooms at the end of the hour while receiving no therapy.
So I will always recommend that someone accompany their loved one to the various therapies just to make sure they're actually being done.
When dad broke his hip and went for rehab, he wasn't making enough progress by Medicare standards, so he was discharged from rehab. I had to find he and mom an Asssted Living facility in short order. That was a real nightmare.
I wish you good luck and Godspeed with a difficult situation.