Botched hospital discharge-rehab needed

[youbet]

OP,

Thanks for clearing up the confusion over whether the hospital discharge indicated "in-patient or out-patient" rehab. When you used the term "in patient" in the original post, it threw me off.

It appears your DM should have been sent to an in-patient rehab facility at the time of her hospital release but was sent home and told to schedule out-patient rehab. This happens. Patients often want to go home (badly) and demonstrate as best they can that they are able to do so. Sometimes they exaggerate the amount of help they will receive at home. Sometimes they regress after they're home. Sometimes the hospital staff just misses the call. But the situation can be reversed.

At this stage I wouldn't count on hospital staff being the primary movers on getting her admitted to an IRF or taking responsibility for her ongoing progress.

According to the Medicare site (actually I used the "What's Covered" app), you have 60 days from your DM's hospital release to get her admitted to an IRF (Inpatient Rehabilitation Facility). Getting your DM admitted at this stage will likely involve her PCP getting involved if he/she isn't already. The hospital docs have moved on and will be tough to reel in. Does she have a PCP and does that PCP have privileges at the hospital your DM was admitted to for five days so he/she has ready access to records and data?

Your doctor must certify that you have a medical condition that requires intensive rehabilitation, continued medical supervision, and coordinated care that comes from your doctors and therapists working together.

How did your DM come to be admitted to the hospital? Her doc referred her for hospital admission? She had some kind of incident or detioration at home and was taken to the ER?

 

[youbet]

Op who is your Moms primary Dr. I think they might help you out...

+1

More and more folks don't have a PCP these days and instead rely on seeing various specialists. Since with traditional Medicare, that can seem to work fine since referrals are not required, it's easy to overlook the fact that there is no one to oversee a patient's overall medical situation which might involve multiple hospitals, multiple specialists, labs, rehab facilities, etc.

Hopefully there is a PCP OP's DM has seen who will step in.

 

[bevette]

Does the hospital have an ombudsman or patient advocate? They might be able to intervene on your behalf.

Thank you for this suggestion. I have reached out to this department and am awaiting a response.

 

[bevette]

In my experience, rehab is ordered before discharge and the patient is directly admitted from hospital to rehab.
After the fact must be horrible to coordinate.
Things to try:
Contact the hospital social services department to see if they can help.
Contact her current PCP for drs order.
Contact your local aging services in your city for assistance.

Best of luck and good wishes for better heath for your Mom

Great suggestion. I have reached out to her PCP. No response yet.

 

[Aerides]

The hospitalist has ignored all my calls. His number only has an answering machine. And there’s no social worker listed on paperwork.

Do you live close enough to go in person to the hospital?

 

[bevette]

Do you live close enough to go in person to the hospital?

Yes, we are very close to the hospital.

 

[bevette]

Wanted to close the loop and thank everyone for their thoughtful comments and suggestions. We have come to discover that the attending physician from her hospital stay did place an order for PT (but not rehab). We discovered this when a PT called to schedule an initial visit. There were absolutely no comments in the discharge orders that PT had been ordered. My mother is now receiving in home PT.

My takeaway from this experience: carefully review the discharge papers PRIOR to discharge and insist they contain in writing orders for PT, OT, rehab. Also to have an in-depth discussion with social worker/case manager prior to discharge to ensure alignment with expectations on post-hospital follow up orders (and to capture their name/contact info).

 

[samcat]

I haven't read all the posts, but if she isn't stable, I would take her to the emergency room and get her admitted again. Then start over and get the hospital to refer her to a rehab. My 87 year old mom fell and broke her wrist and hip last week. She spent four days in the hospital and then was transferred to rehab in an ambulance. She is now getting PT, OT and speech (for memory issues) everyday.

 

[Lstansbury]

After many years of dealing with my mother's and sister's health issues I would suggest taking her back to hospital for readmission. I believe to have rehab covered by medicare it requires three days stay in hospital which they know. I would make calls to hospital administration and ask for Social Services manager.

Yes. I had forgotten about this until I read your post. Kicking her out without having rehab arranged was awful. You could also call the beneficiary protection QIO for your area, there should be a hotline to complain to. The folks answering the phone will try to intervene on her behalf as well. It is a Medicare contractor company designed to help with situations like this.

 

[Lstansbury]

Google Medicare QIO, beneficiary protection hotline. There is one for your area. That person will return the call quicker than the patient advocate.

 

[bevette]

OP,

Thanks for clearing up the confusion over whether the hospital discharge indicated "in-patient or out-patient" rehab. When you used the term "in patient" in the original post, it threw me off.

It appears your DM should have been sent to an in-patient rehab facility at the time of her hospital release but was sent home and told to schedule out-patient rehab. This happens. Patients often want to go home (badly) and demonstrate as best they can that they are able to do so. Sometimes they exaggerate the amount of help they will receive at home. Sometimes they regress after they're home. Sometimes the hospital staff just misses the call. But the situation can be reversed.

At this stage I wouldn't count on hospital staff being the primary movers on getting her admitted to an IRF or taking responsibility for her ongoing progress.

According to the Medicare site (actually I used the "What's Covered" app), you have 60 days from your DM's hospital release to get her admitted to an IRF (Inpatient Rehabilitation Facility). Getting your DM admitted at this stage will likely involve her PCP getting involved if he/she isn't already. The hospital docs have moved on and will be tough to reel in. Does she have a PCP and does that PCP have privileges at the hospital your DM was admitted to for five days so he/she has ready access to records and data?




How did your DM come to be admitted to the hospital? Her doc referred her for hospital admission? She had some kind of incident or detioration at home and was taken to the ER?

DM was taken to ER via ambulance. A “non-life threatening” emergency call, which eased her panic. Her PCP has been helpful post-hospital stay. It actually didn’t occur to us to engage the PCP earlier. You don’t know what you don’t know.

 

[youbet]

DM was taken to ER via ambulance. A “non-life threatening” emergency call, which eased her panic. Her PCP has been helpful post-hospital stay. It actually didn’t occur to us to engage the PCP earlier. You don’t know what you don’t know.

Are you satisfied with the current situation with your DM living at home and receiving in-home PT?

 

[bevette]

Are you satisfied with the current situation with your DM living at home and receiving in-home PT?

We are 1.5 weeks post discharge, and now that we have outfitted the house with functional devices (toilet risers with handles, adjustable width walker, shower seat), the situation is manageable. The dicey time was 2-3 days post-discharge when she was sent home, we had no devices in place except an old walker that’s too wide to fit through doorways, and we had no idea if PT had been ordered. I thought she needed at least a couple days in in-patient rehab where she could get assistance toileting and getting used to PT while the family outfitted the house.

 

[1242Vintage]

Similar thing just happened to 97 y.o. FIL. Discharged with the “promise” of in-home therapy, visiting nurse, oxygen, etc., etc. Services were spelled out in discharge orders.

None called to make appt or showed up!

Sadly he ended back in ER within a couple days. Dear wife is on point now to be the extremely load and squeaky wheel to get him the in home care and services promised @ discharge. And believe me no one ever should be on the pointy end of my lovely wife’s stick. Took her being the very loud advocate to get him the rehab and support services promised and needed.

 

[RetiredHappy]

Similar thing just happened to 97 y.o. FIL. Discharged with the “promise” of in-home therapy, visiting nurse, oxygen, etc., etc. Services were spelled out in discharge orders.

None called to make appt or showed up!

Sadly he ended back in ER within a couple days. Dear wife is on point now to be the extremely load and squeaky wheel to get him the in home care and services promised @ discharge. And believe me no one ever should be on the pointy end of my lovely wife’s stick. Took her being the very loud advocate to get him the rehab and support services promised and needed.

During discharge, discharge planners are supposed to share a list of home health agencies for the family to see if they have a preference. If the family has no preference, the discharge planner is supposed to call a home health agency that could take the patient, and if the home health agency is unable to take on the case, to work down the list until a home health agency which could take the patient. The paperwork is then faxed to the home health agency and the family told which agency is going to follow-up. Hence, it is very important that an advocate/family member is there during the discharge.

 

[tango2]

Call nursing supervisor if hosp. Call during day shift probably 8-9am to about 3pm. If a large hosp they will have a patient care team dept. that may not be correct term for it but hosp supervisor will know. Good luck