Medicare about to stop paying for my mom’s rehab. What do I do?

March 15, 2019 11:28 AM

My mother is not cooperating with rehab after a fall. I don’t know what to do. Details below the fold.

My mother had a fall a month ago. She was in the hospital for two weeks and then discharged to a skilled nursing facility about three weeks ago for physical therapy before being sent home.

The social worker just called me to say that she is not cooperating with the physical therapy and that he needs to put that in his progress report. The facility will use that information to submit the request to Medicare to pay for her stay. My understanding is that they update Medicare on her progress week by week (Medicare will approve paying for it week by week.)

My mother is withdrawn and depressed and finds the physical therapy very painful.

If Medicare refuses to continue paying for her care, the social worker said that she can stay at the facility but it will be cash pay. This is about $8000/month.

What do I do? She is in no condition to go home, even if I had a hospital bed put in her house and arranged for aids to come in to help her.

If I was able to get her home, is home physical therapy a possibility?

I'm in California.

Thanks in advance

posted by fozzie_bear to Health & Fitness (10 answers total)

I don't have an answer to your Medicare quagmire, but in-home physical therapy is definitely A Thing. Hell, I work in medical tourism and physical therapists will come to a hotel room.
posted by zeusianfog at 11:40 AM on March 15, 2019 [1 favorite]

If she's got untreated depression, that needs to be addressed by the medical staff at the facility. I'd also question how good her pain management is if the physical therapy is intolerably painful. Frame these as medical issues that are not being managed well and ask to have her evaluated for both and try to make sure you're there for the doctor's visits. It's possible she's not reporting well and is minimizing the issues when she sees her doctors.

Have you told her frankly what's at stake? Does she understand?
posted by quince at 11:42 AM on March 15, 2019 [14 favorites]

If you feel the skilled nursing facility isn't handling this right and is in some way responsible for her lack of compliance that may lead to a cutoff of funding, you can call the Office of the Ombudsman.

If she does end up getting discharged, I guess I'd say just be ready to call 911 and have her hospitalized again if she's not doing ok. And talk to a social worker at the SNF or the hospital about home health visits. I know plenty of people get visits from nurses for a while after discharge from a hospital and think probably pt, too, but I'm blanking on whether I've specifically seen that to be a thing.

Meanwhile, ask the social worker if Medicare is likely to cut off funding after one report of non compliance with physical therapy. I don't know the workings of Medicare. I'd hope they'd better understand that people aren't always perfect patients.
posted by Smearcase at 11:56 AM on March 15, 2019 [3 favorites]

My mother was sick with cancer in a rehab. She hadn't eaten in 2 weeks and was vomiting in a pan and the physical therapist was trying to make her try to walk despite being too weak to stand. While. She was. Heaving. They said she wasn't cooperating. Her doctor didn't want her doing rehab. She died soon after from an infection from the IV. Please make sure your mom is physically able to do rehab and there isn't an underlying problem.
Good luck and I am sorry you are going through this.
posted by beccaj at 12:21 PM on March 15, 2019 [6 favorites]

Home PT is a thing, but you need to be honest with yourself about what her condition is. Can she get up and use the bathroom (or a potty chair) and return to bed by herself? If not, can she do it with your level of assistance -- like, a hand to steady her? Or does she need more skilled assistance to get her up and down? In my experience, this issue -- whether or not a person can use the toilet by themselves -- is the breaking point between what you can reasonably accomplish at home and what you can't.
posted by BlahLaLa at 12:25 PM on March 15, 2019 [4 favorites]

Boy, these situations are never easy. I'm sorry you're having to deal with this.

Your questions might be best posed to the rehab facility social worker. IME they can be enormously helpful in evaluating what's going on, figuring out how to solve any problems, and helping you navigate the system. Use him/her as much as you can.

You didn't mention your mom's age or anything about her mental alertness, so please forgive me if I'm way out of line here. Again, IME, people often present as you described - reluctant to do therapy, withdrawn - when they have given up on life. My mom (but not my dad) was candid and self-aware enough to come right out and say that she "wanted to let nature take its course". I guess what I'm trying to say here is that it would be very helpful if you knew what her thoughts and wishes were, then you could be her advocate rather than assuming that she wants to get better.
posted by DrGail at 1:02 PM on March 15, 2019 [4 favorites]

If Medicare will not pay for your mom, you can appeal. Even if the appeal is not accepted, they have to look into it, and that will give you a couple more days to find a new place/solution of some sort. My impression is that unfortunately Medicare has a narrow window for paying for rehab -- the patient has to still need the rehab, but also be progressing rapidly.

I want to second DrGail's advice to use the rehab facility social worker. Helping you figure this out is part of their job. They might not approach you, you may need to make an appointment to talk to them. If you are sure that your mom can't live at home, they may have people who can tell you about group homes in your price range and drive you around to show you several (in our case, this guy got kick backs from those places.) If you had to limit your choice of rehab places due to insurance issues or perhaps space issues, you might want to call your preferred nursing homes again. If you are paying out of pocket, it might as well be a place you like. You might also want to talk with the social worker about hospice. Hospice doesn't require that the patient die within six months, getting better sometimes happens too.
posted by SandiBeech at 2:25 PM on March 15, 2019 [1 favorite]

My mother (who had suffered a stroke that severely weakened her left side) improved so much after she got home from a rehab facility that it was incredible. She did not walk at the nursing home -- no one tried it. It was as if they were simply going through the motions; they really seemed to think that she would not go home at all, but would become a resident there. Her physical therapy involved a stationary cycle, for the most part. At home, within a day or two of her release, a visiting physical therapist had her walking, with help. Before my mother came home, we all thought the rehab place was the safest and best place for her, and we were frightened, really terrified, about her return -- no one knew what to do. I fought hard, in fact, for her to stay longer than the rehab wanted to keep her, which I now regret very much. Not that I got pushy about it (I did, but I don't regret that part), but that she was allowed to stay for longer, and she would have been happier and stronger at home.

The physical therapy department at the rehab was made up of nice people who did not really see my mother as someone who could walk again. Her case manger blithely said she could progress no further after scarcely anything was tried. The administration seemed only to see her as a person with Medicare; they were in fact pretty awful.

I am getting sad now thinking about this again. Every case is different, and your mother's circumstances sound generally different from my mother's, but if your mother is at all strong, she might just do better outside of the rehab. Those places are depressing, and they do not seem to be designed to make elderly people feel good.
posted by Francolin at 9:12 PM on March 15, 2019 [4 favorites]

This sounds so hard, and I don't really have any advice. But I wanted to chime in that yes, home health is a thing. I've had home health nurses, physical therapists, occupational therapists, and speech language pathologists visit me right here in my room. All the best.
posted by The Almighty Mommy Goddess at 12:27 PM on March 16, 2019

I bet California has some great advocacy organizations that could help you with this. Unfortunately, with health care advocacy, the key is persistence, so just keep calling people until you find someone with the knowledge and desire to help you find the path that ends with a reasonable result for you and your mom.

On first search, I found a couple of California orgs. Maybe looking at these will give you a few ideas on who you might call?

Legal aid sounds like it might be appropriate here as well. I agree that it sounds like the facility might be booting your mom for reasons that have nothing to do with their responsibilities, and everything to do with their own bottom line in one way or the other. A letter from a lawyer might be all you need.

Here's what I've learned from my own mom, who has spent her life working on providing better health care to under-served and rural populations in the good ol' US of A: NEVER take anyone's word on its own. Always ask questions, think hard about the answers, ask more questions, ask more people, and keep asking. Eventually, you will probably find a human being who gives a shit, and often, that's all you need to completely change a patient's life.

I'm sending positive vibes your way. Good luck.
posted by nosila at 6:21 PM on March 16, 2019