My mother needs care but her "care plan" is conflicted.

5 answers | Last updated: Oct 27, 2016
Dtellie asked...

My mother fell a few months ago, was hospitalized, then entered a rehab. After a few months they said her "care plan" doesn't indicate she needs skilled nursing and wanted to place her in an adult home but adult homes don't handle people who are on oxygen 24/7 (emphysema) plus she has macular degeneration and can barely see and can't read at all. So I fought them and even had the ombudsman go to a care plan meeting. The rehab center said they have an opening in one of their nursing homes for her and I took it.

She has been there 3 weeks and now I get a letter that says that her care plan hasn't changed and they will stop billing Medicare. I already applied for Medicaid and it was just approved.

My mom can 'feel' her way to dress and eat but can't prepare foods, can't see to take the medication the proper way so I don't understand why they didn't score her for skilled nursing. She has a history of blackouts and major depression. So my question is...can a nursing home (who is medicaid approved) make her leave because a care plan doesn't indicate she needs skilled nursing? Will Medicaid pay for her care in a nursing home even though the PRI (patient review instrument) done by the rehab indicates she is not nursing home material? I am worried they will kick her out on the streets and I can't take care of her in my home for many reasons including a disabled husband and son already living with me.

Expert Answers

Kay Paggi, GCM, LPC, CGC, MA, is in private practice as a geriatric care manager and is on the advisory board for the Emeritus Program at Richland College. She has worked with seniors for nearly 20 years as a licensed professional counselor, certified gerontological counselor, and certified geriatric care manager.

In spite of all the recent publicity, many caregivers are surprised to learn that Medicare does not pay for long term care, no matter what the circumstances or the diagnosis. This is the reason the nursing home and the rehab facilities cannot continue to bill Medicare for your mother's care. Medicare will cover a certain number of days with a maximum of 100 days. Your mother has exceeded that limit and so is no longer eligible for Medicare.

That brings up the question of Medicaid. Medicaid is a joint venture of the federal and state governments. The specifics of who is eligible for Medicaid vary from state to state. Medicaid was created to pay for care for people who are indigent, who need care and cannot pay for it. Apparently your mother meets the criteria for Medicaid in her state because you said she has been approved. She should be able to stay in the facility where she has been approved as long as she needs care. My understanding is that it is illegal to discharge a patient from a care setting if they have no other place to live. Your state ombudsman will be able to speak to this issue better than I.

A person who cannot see well enough to manage their medications or prepare a meal but is otherwise healthy is better suited to an assisted living community. Assisted living provides assistance with the tasks of daily living but not skilled nursing care. Some states have such communities that accept Medicaid reimbursement. Ask her Area Agency on Aging if her state has these communities, and then find out how to qualify.

If there are no such communities locally or there are no openings, she should be able to stay where she is now.

Community Answers

Jenaette answered...

Even though many facilities accept Medicare for the initial 100 day period, many do not accept state long term care. This is not a physical issue, but more of a monetary one.

I discovered that has long as I had the liquid assets (cash) to pay for Dad's care that anyone (everyone) would take him, including those who did not have the expertise to care for a Senior with Alzheimer's disease and a stroke. Dad could not stand for transfers, weighed 200 lbs and was 6'4". This has always been fully disclosed in writing, but has created ongoing care issues.

You are incorrect to state that the facilities "can not put an elder out in the streets". They do it every day. It'r referred to as "Dumping". When a facility can no longer care for an elder, or they do not want the family asking questions, or they simply need a power boost, they simply call for an ambulance to pick up the resident and send them to the local hospital without physical symptoms or complaints of their own, and without contacting the family!

The facility then refuses to accept the resident back, leaving the Elder abandoned in an emergency room without a representative. The family is ususally notified by the ER physician, who is unaware that he was just duped by the administrator of an Edler Care facility who used him for personal gain.

I know first hand. That happened to Dad, without as much as a courtesty call from the facility, which was a large corporate owned facility for the memory impaired. The ER report stated that they "could not care for the resident" that they were "NOT a Memory Care Facility". Funny the sign on the front of the building read "Hawthorne Court, a Memory Care Facility". Dad has just been released by HOSPICE that day back to the facility with the approval of the nurse at the facility. Dad lost his deposit, and his monthly fee that had just been paid the day before. I had a police report filed against me for "stalking" while I sat unaware in my home. The ombudsman's office could do nothing!

When will the "experts" begin to understand the real world of elder care; that Elder Care is the largest unregulated multi billion dollar industry in existance, and that the owners of these facilites do not want to be regulated for fear of losing their right to financially expolit the consumer, thereby increasing their profits exponentially.

A fellow caregiver answered...

Medicare Part A is a benefit for those who have been in the hosp 3-nights and discharged in need of rehab for whatever they were admitted to the hosp for that period of time.Once they have met their goals they are discharged from rehab. Medicare part B will pay for therapy at home as well as a visiting nurse for a short period of time. You can always stay at the facility if you are willing to pay for private care. They only try to "bump" when the family is the problem.Your Mom would do well in an assisted Living and it would be less costly.Try to remember this would be her home. Watch out for her,do your homework, but don't be a problem for her.

A fellow caregiver answered...

What an eye opener. If the facility does not "like" the family, who is responsible for their parents care, they just "dump" the paying resident and keep their money? Thanks for sharing, I had no idea this was legal. Where can we get a list of the facilities that have done this?

A fellow caregiver answered...

I totally agree with your statement "Elder Care is the largest unregulated multi billion dollar industry in existence." There is so much red tape and gray area it is truly unbelievable. Besides the fact that there is no communication it seems this industry is one that has the constant "revolving door" syndrome. Employees come and go... a new person every month including the Executive Directors and Directors of Nursing. Then what comes with that is that new person getting to know your Family Member and then you do it all over again and again. Frustrating to no end.

My husband have been caregivers from my Mother in Law for 6 years now. She does not live with us (that would never happen) but has been in an Assisted Living Facility for 5 1/2 yrs. and recently moved to the Memory Center in a large company and quite expensive.

As far as the expense, yes ALF is much cheaper than a Nursing Home but recently this large company with facilities all over the US has put a new "Care Plan Assessment" into place. They charge you for every little thing. Before we moved her to the Memory Center they informed us we would be getting a $1200 increase in her Personal Plan. $500 of that was because she does not cooperate all the time. Yes, $500 extra because she can be difficult like many of the elderly. Believe me, I know my Mother in Law... My advice putting your Family Member in a ALF be sure to understand your contract and how they charge for the Personal Care Charges.