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Nursing Home Admittance Example
Old 08-12-2013, 01:11 AM   #1
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Nursing Home Admittance Example

DW and I recently placed her mom in a NH here in Illinois. We learned a lot from the process. Here are a few quick observations I made as we waded through the ordeal.

1. Here in northern Illinois, NH's that will accept a patient who is on Medicaid (near zero assets) from the get-go tend to be dumps with bad care and low ratings. When mom left the hospital and went to one of these for two weeks as a rehab patient under Medicare, we found out what being in a bad NH meant. We were really glad to get her home and out of there. Because this was a Medicare, not Medicaid, situation there were plenty of better NHs available for her and we were guilty of not researching and knowing this. We allowed her to be sent to a NH known for accepting Medicaid patients when Medicare and her supplemental policy were paying. Bad, bad kids.

2. Many better nursing homes have Medicaid residents but they are residents who started as private pay but outlived their money and switched to Medicaid. Better NH's have no need to accept Medicaid patients as they attract plenty of folks who can private pay, at least for a while.

3. Better (read "highly rated and likely expensive") NH's want new residents to show that they can private pay for two years before they accept them and guarantee they can stay, with Medicaid paying, if they outlive their money.

In mom's case, she had a second need for rehab NH care (paid by Medicare) following another hospitalization and we had located a much better facility for her this time. Medicare pays for 100 days of NH rehab and at a high enough rate that better NH's readily accept patients. Mom also had the remaining line of credit from her reverse mortgage and a modest monthly SS check. This all added up to being private pay for roughly one year. That is, 3 months of NH rehab paid for by Medicare + supplement and 9 months of NH residency as a private pay.

When it became apparent she wouldn't be coming home from the NH rehab, we applied for her admittance as a resident and she was accepted. Despite falling short of the requested two years of private pay money, they had good knowledge of her due to the 100 days she had spent there as a rehab patient on Medicare. They knew she wasn't a screamer, wanderer or roommate hater. She's just wheel chair bound and needs help getting to the dining room and toileting. Thank goodness.

In her case, having no LTCi hasn't been an issue. There is no spouse to be impoverished. No one needs any inheritance and, regardless, any inheritance would have been a pittance anyway. She had just enough private pay money to get her into a highly rated (think almost $90k/year in a two bed room) NH who will keep her after she moves to Medicaid next spring. We couldn't have gotten her into a better place even with LTCi as far as I can tell.

Her reverse mortgage turned out to be a blessing. We took it out at the peak of the housing bubble. The residual value of the line of credit when we closed it out was greater than the most optimistic current value given us by realtors. The reverse mortgage actually gave her some protection from the housing bust.

Bottom line = a single person with no dependents and few assets doesn't need LTCi. Having enough money to pay for a year or two of LTC before Medicaid kicks in is very helpful in getting into a "better" place. Being in a "better" place relieves your kids from the worry of having you in a poorly managed, poorly ranked/graded dump.
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Old 08-12-2013, 01:32 AM   #2
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Both of my parents required some weeks in Nursing Home care for rehab stints after hospitalizations. Even for private pay patients, we found that the places with nicer locations and more highly recommended by doctors were hard to get into. They were almost always full with a waiting list and would not accept any Medicad patients (although they would accept Medicaid payments for long term residents who started as private pay).
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Old 08-12-2013, 08:24 AM   #3
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Thank You that is helpful info. That also saves us a lot of worry.
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Old 08-12-2013, 08:33 AM   #4
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OP is fairly consistent with my experience. The better places prefer private pay for a while before Medicaid, however in the end there are both Medicaid and private pay patients alongside each other and the care is the same for both from what I have seen.
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Old 08-12-2013, 08:36 AM   #5
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Here's hoping I live a long, reasonably healthy life, then just keel over dead...

I do have LTCi, though, assuming I can continue to afford the premium...
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Old 08-12-2013, 08:38 AM   #6
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Been there, done that. And those were my experiences as well.

I also learned that when it comes to end of life decisions, it takes an act of Congress to get a private-pay patient into hospice. That private $$ keeps them afloat.

Thanks for sharing your story. Most people have little to no experience with any of this, and when you do need it, it's often a crisis situation, which makes good decisions pretty darned tough. Sounds like you did lots of the right things. Good on you.
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Old 08-12-2013, 09:37 AM   #7
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The facility my in-laws were at would ask people to move if they ran out of money. I saw it happen twice in the years my in-laws were there. They wouldn't carry anyone on medicaid. It was a pretty nice facility that was run by a religious organization. The cost was on the low end of other facilities in the area so their unwillingess to subsidize medicaid patients made it cheaper, better for those that could pay.

There wasn't any hesitation to put either of my in-laws into hospice. The conversion to hospice was guided by the facility determining that with their normal care the patient was within 6 months of passing away. With my MIL, she lasted 2 months. My FIL went over a year. After he was in hospice about 6 months, my wife and I planned a trip to Europe almost 9 months later. We both agreed he couldn't last that long. He soon rallied and the facility was about to take him off hospice the month before our trip. About 2 weeks before we were to leave, he suddenly got much worse. A week before the trip the facility suggested we cancel our trip. My FIL passed away on the morning we were supposed to leave. I've always considered that he saw this as his last chance to screw up my life and he took it.

Hospice really didn't do anything different except withdraw most medications except pain meds. The hospice nurse would visit several times each week.
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Old 08-12-2013, 12:03 PM   #8
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My understanding is that around here while they can ask a resident to move they can't actually force a resident to move because they can't just push them out the door and leave them outside (duh!) so in the situation you describe a family could just refuse to move them and the resident would end up on medicaid whether the facility wants them or not.

Your hospice comments confuse me. I think of hospice for terminally ill where they are being cared for at home (or a close relative's home) but from what I know it would be rare for someone to move from a nursing home back to their own or a close relative's home for their final days - they just stay in the nursing home.
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Old 08-14-2013, 04:12 PM   #9
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Originally Posted by pb4uski View Post
OP is fairly consistent with my experience. The better places prefer private pay for a while before Medicaid, however in the end there are both Medicaid and private pay patients alongside each other and the care is the same for both from what I have seen.
That's what we've been promised and what we're expecting. MIL is in a Medicaid qualified bed now despite temporarily being private pay. People who run out of money (in Illinois) while in one of the NH's "Medicaid qualified beds" are guaranteed staying. If they are not in a Medicaid qualified bed when they run out of money, they are moved to a Medicaid qualified bed if available. (In better NH's, Medicaid qualified beds are seldom available.) If none is available at that time, they can be moved to another NH that has one. That place, if it's one of those specializing in Medicaid residents, might not be as"pleasant.''

I have no idea how they would force this move. And I don't want to know.

In the better homes, it seems to be a juggling act of keeping the Medicaid qualified beds occupied by residents who were already private pay residents for some time but who eventually ran out of funds.

BTW, there are three levels of rooms in this facility. Single. Double with both roommates sharing the bath. Double with a bath that connects to 2 rooms so 4 residents share the bath. The later are the "Medicaid qualified rooms."
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Old 08-14-2013, 04:50 PM   #10
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Quote:
Originally Posted by pb4uski View Post

Your hospice comments confuse me. I think of hospice for terminally ill where they are being cared for at home (or a close relative's home) but from what I know it would be rare for someone to move from a nursing home back to their own or a close relative's home for their final days - they just stay in the nursing home.
What you are missing is that someone can be in hospice while in the nursing home. DH's mother was in a NH and went on hospice...and proceeded to live another 5 years or so.
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Old 08-15-2013, 08:33 AM   #11
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Originally Posted by pb4uski View Post
Your hospice comments confuse me. I think of hospice for terminally ill where they are being cared for at home (or a close relative's home) but from what I know it would be rare for someone to move from a nursing home back to their own or a close relative's home for their final days - they just stay in the nursing home.
Katsmeow is correct. From my 7 year intimate contact with the continuing care industry, I would say most nursing home residents go into hospice at some point. The only exceptions are those who have sudden heart attacks or strokes. On my FILs first night in skilled nursing, his roomie passed away with a heart attack (Lucky b*st*rd and lucky family). Anyone in assited living or memory care are usually transferred to skilled nursing long before hospice is started.

At some point for most patients, their physical condition deteriorates to the level that there is no point in continuing the treatments they have been recieving. The switch is made to controlling pain and making the patient as comfortable as possible.
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Old 08-15-2013, 03:26 PM   #12
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Your hospice comments confuse me. I think of hospice for terminally ill where they are being cared for at home
Around here, we have two types of hospice care (two different hospice providers). One provides their service in the hospital or nursing home or assisted living facility where the patient is. The other has their own facility where the patient is admitted.

I learned about this a few years ago when my mom was in a local hospital and things were looking dim for her. I got a call from a palliative care nurse [never knew there was such a specialty!] who explained all the ins and outs to me. She gave me a full education on the options during a 20 minute phone call, and I was extremely grateful.

If anyone is facing such a situation, it might be worthwhile seeking out such a person at a local hospital and making an appointment for a consultation.
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Old 11-29-2013, 05:57 PM   #13
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Wonderful post. Going through this right now and researching what to expect. Your post was what I was looking for. Thanks.
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Old 11-29-2013, 06:52 PM   #14
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My mother is recovering from a stroke. She had several days (7 or 8 maybe) in NICU, 3 weeks (I think) in rehab in hospital, and another 2 weeks in a special care unit in hospital. She went home with my sister and we're paying for sitters while sister works. Mother has no assets and we are trying to keep her out of NH but who knows how long (1) sister can care for her, and (2) we can afford sitters while sister works.

I truly don't want to be a burden to my only child, so it's good to know that most NH don't kick you out should you outlive your money.

My MIL lived about 2 yrs in NH, and at some point, her care was turned over to hospice as the NH team determined that she was in a "failure to thrive situation" (I think that was their term). She passed about a month later, and in her case did not outlive her funds, thankfully.
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Old 11-29-2013, 06:57 PM   #15
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I realize that this is an older post, but a good one. I'd add that one problem we ran into with FIL was that the nursing homes were in such demand that when he needed to be hospitalized while a resident at the NH, you either had to continue to pay for his room (out of pocket) or basically get tossed out and start the search for a new NH when he was released from the hospital, which could be on very short notice. So, trying to establish a track record at a "good" NH to pave the way for Medicaid acceptance was difficult.
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Old 12-01-2013, 09:07 AM   #16
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My understanding is that around here while they can ask a resident to move they can't actually force a resident to move because they can't just push them out the door and leave them outside (duh!) so in the situation you describe a family could just refuse to move them and the resident would end up on medicaid whether the facility wants them or not.

Maybe laws vary by state?

We placed my mother in a Alzheimer-focused NH last December. They do not accept Medicaid and were very clear about that upfront. They ask that you notify them when you are within a year of running out of money and they assist you in finding a placement in a nearby NH that accepts Medicaid.

Could I not tell them when she is within a year? Sure - and I am sure they couldn't "toss her out on the street". But they could and would, at that point, have her moved immediately to the first bed available in a Medicaid-accepting NH - which might end up being 1) a "less than stellar" place and 2) be hours away from here. As a private-pay home, they are not obligated to keep her long-term.
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Old 12-01-2013, 09:31 AM   #17
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interesting post and replies. My Mother is 84 and in good health, thank goodness. But a time will come when her situation will change. In preparation, I've got a meeting with an eldercare attorney next week to discuss the what if's and get a little education on assisted living, NH and even reverse mortgages for the elderly. My mother has TriCare medical but I have no clue how LTC fits into that or if medicare becomes primary... I need to do more research..
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