Be Wary of Rehabilitation Facilities in Skilled Nursing Homes

[Teacher Terry]

I have a friend wanting to return to his apartment in a assisted living facility. He was in a rehabilitation wing of a skilled nursing facility for a week for physical therapy after a month hospital stay and wanted to return home. He has privacy in his apartment yet all his needs are met when he either requests them by pushing the button on his pendant or it’s time for his medication. Despite the nursing home knowing his desires and receiving the transfer paperwork from his assisted living facility they told him he was staying. I immediately drove over and the doctor was bullying him telling him it wasn’t safe to leave and not listening to him. The facility called one of his other friends complain that he wasn’t cooperating and that she needed to convince him to stay. She told them he was going to a safe environment.

In my discussion with the doctor I let him know that I was a retired social worker and that where he lived could meet all his needs and the doctor was arguing with me. I finally told him it wasn’t a prison and he couldn’t keep him there. He let me know that he could declare him incompetent and keep him. I let him know that I would request a immediate competency evaluation which he would pass. In the end he finally discharged him saying we would be sorry and he would be back. Then he said he was relying on my professional opinion as a social worker.

My theory is that the facility wanted to keep him for the 21 days that Medicare would pay for rehab. Ironically where he lives provides much better care than the nursing home. He even gets physical therapy at his place. Anyway I have decided that I will never consent to go after a hospital stay. You have more rights when leaving the hospital and a hospital doctor has no incentive to pull that unethical behavior.

 

[RetMD21]

I'm glad you were there for him. A lot of money is made on those post-acute care stays. Sometimes the patients even benefit.

 

[Teacher Terry]

RetMD, I haven’t known one person that has went to one actually benefit. This includes different people in different states.

 

[RandomPJ]

What is the 21-day rule? (I'm going through a learning process for all this for a family member.)
Thanks.

 

[retire to nature]

I am pretty sure, the dr in snf was paid from the snf. And pandemic would cut off profit of snf also. I used to work in a snf, and healthcare is a business more rather than a illusion ppl would think ethical activity.
I used to work a hospice care too and I realized what unethical things are done in the field too.
I guess one of my FIRE is related too and I dont believe much in healthcare anymore.

 

[retire to nature]

What is the 21-day rule? (I'm going through a learning process for all this for a family member.)
Thanks.

I dont know exactly but I would guess medicare would pay for 21 days after a hospital stay. Then snf can get profit to have the pt in the snf.

 

[Teacher Terry]

Medicare will pay for 21 days of rehabilitation after a inpatient hospital stay provided the doctor says you are improving. It’s not considered custodial care which Medicare won’t pay for. Since my friend left after 7 days they are losing 14 days of payment unless they can fill the bed.

 

[Amethyst]

Why didn't the doctor simply order a competency test? That way it wouldn't be your word against the doctor's; the test results would rule the day.

 

[retire to nature]

Why didn't the doctor simply order a competency test? That way it wouldn't be your word against the doctor's; the test results would rule the day.

The Dr can be an employee of snf. The Dr could be working on the sensus of pt.
A snf hires a dr to be the director dr of the snf. So it could be a political issue not medical or ethical issue.

 

[retire to nature]

work a hospice care too and I realized what unethical things are done in the field too.
.

I just wanna add this.

I loved the hospice field due to the service of the hospice philasophy but the company was doing unethically to modify the days of stay to get paid by medicare or medicaid. So same as the Dr, when I was an employee there, I cant do much because my pay was coming from the company.

 

[Teacher Terry]

I am sure he didn’t order one because he knew my friend was competent by talking to him. My friend has been severely hearing impaired since birth which impacts his speech. Despite my friend having a master’s degree and a career people don’t want to take the time to actually listen to him. Due to his Parkinson’s his speech is not very loud. When I arrived the doctor wasn’t listening to him and in fact was bullying him.

 

[audreyh1]

Wow!

 

[Teacher Terry]

I decided to go online to leave a review and there’s a ton of bad reviews of both the facility and doctor. One said only put your family member there if you wish to kill them.

 

[RunningBum]

I'm glad you were there for him. A lot of money is made on those post-acute care stays. Sometimes the patients even benefit.

RetMD, I haven’t known one person that has went to one actually benefit. This includes different people in different states.

We did, with my Mom, just a month or so ago.

She was in memory care, and took a fall walking maybe 25 feet to lunch with my dad, and broke her hip, or something in that area. Had surgery (necessary to relieve pain even if she couldn't walk again) and some PT in the hospital while she recovered and we tried to find a place for her. The memory care center had already warned us that they couldn't keep her if/when she needed more than one person to help her out of bed. It was clear that she wouldn't be going back there.

The social worker recommended another place that could give her rehab, and also took memory care and could handle her lack of mobility. It costs a lot more, but they take Medicaid if she had enough to cover 6 months, which she does. We also heard from other sources it was a good place. So they moved her from the hospital to there, where she spent maybe a week or 10 days in rehab, and Medicare paid for all of this including the room. Probably about $2500 to $3000 that we didn't have to pay anything at either her former place or the new place. She seemed much happier at this place and we all liked it too, and she was able to transition to the long term care for her dementia and limited mobility in the same room.

It was a very fortunate set of circumstances that landed her in a rehab place that she could stay at and do better in than she was before, and had that short term windfall of a break on her expenses. My brother and I got the Medicaid process started to prep for splitting their assets so my Dad won't run out of money due to her expensive care.

Your warning is good but this is a case where someone benefited.

 

[Teacher Terry]

Running bum, I am glad it worked out well for your mom. I know with dementia balance seems to be negatively impacted.

 

[Bamaman]

You never know when a physician has alternative motives. For example, a number of doctors often own outpatient surgery centers--where you're steered for day surgeries.

Assisted living facilities are like full nursing homes in that they're not all created equal. Some give better services than others.

My wife was held in the hospital 5 days after a mid foot fusion surgery a year ago so she would be eligible for a full rehabilitation--mostly teaching her how to deal with the foot. They taught her mainly how to hop around with a walker--and how to take a shower. When the bill was paid by Medicare, we were surprised to see Rehab about as expensive as staying in the Hospital.

I'm sure that nursing home was also very, very expensive on a daily basis vs. assisted living.

He's just fortunate to have a friend that's trained on how to handle such situations. Many elderly don't have anyone to take up for them.

 

[daylatedollarshort]

We had an issue in the opposite direction with a senior relative getting released too early from the hospital before their condition and medication were stabilized. They collapsed at our home in front our then small kids and I had to call an ambulance. A nurse friend at the same hospital explained to me that the hospital made more money from Medicare with the release and then readmit scenario, and that the ER there was like a revolving door for some seniors.

She told me to refuse to accept release into my care next time until their condition and medication were more stable, which I did. The doctor was not a happy camper but my relative was fine with the longer stay and lived to a rip old age.

 

[mountainsoft]

Yikes, sounds like a nasty facility to deal with. Thankfully we have had fairly good outcomes with rehab centers and assisted living.

My mom had a stroke in 2017 and spent the full Medicare covered 100 days in rehab. From there we moved her to an assisted living where she received a few more weeks of physical therapy (outside agency came to her facility). Other than a few minor issues she has mostly fully recovered. She and I had always hoped she could move back out to her own apartment, but once she got used to the personal care it just didn't make sense. There have been a couple of minor issues with medications (i.e. temporary meds after dental work) and slow response to maintenance requests, but otherwise they've been great.

On the other hand, my wife's mom fell and broke her hip a couple years ago. She spent several days in the hospital, then moved to a rehab center in her home town (1 block away from her house). I think she was there about two weeks before moving back home (she's around 83 years old now).

 

[retire to nature]

We had an issue in the opposite direction with a senior relative getting released too early from the hospital before their condition and medication were stabilized. They collapsed at our home in front our then small kids and I had to call an ambulance. A nurse friend at the same hospital explained to me that the hospital made more money from Medicare with the release and then readmit scenario, and that the ER there was like a revolving door for some seniors.

She told me to refuse to accept release into my care next time until their condition and medication were more stable, which I did. The doctor was not a happy camper but my relative was fine with the longer stay and lived to a rip old age.

This is what I talk about that healthcare is just a business now. When I was a new grad RN, I was pushed to discharge a pt like that. And I refused to do it since my charting should be backed up to get the reimbursement. I said the vital sign is not stable. The Dr and director didnt like me. I guess I didnt know all the business way at that time. But I am pretty sure all the school teaching and real world has a big gap in all field. But it is one of the reasons why RNs' high turnonver rate is. When I heard the last time, 20% of new grad RNs dont come back to the field.

 

[marko]

RetMD, I haven’t known one person that has went to one actually benefit. This includes different people in different states.

I must be an outlier. My brother had a massive stroke six years ago. After two months at one of the country's best rehab hospitals (Boston's Spaulding Center), I got him into a local SNF. While some of the facets there were sub par (poor communications, spotty nursing), the therapy aspect was incredible which was why I chose it.. So much so that, after insurance ran out, he self paid for an extra six months to keep up the daily therapy. It made all the difference for his recovery. His gains were truly beyond all expectations.

The only notable was that the head of the program begged me to find a way to get him on Medicaid as "we could give him so much more help". Alas, his resources were well beyond any thresholds but he did walk out of there with 100 times better chances for gain.

Like any nursing facility, my daily visits and attention to detail also kept everyone on their toes.. "Oh crap! If his brother comes in and sees this, there'll be hell to pay". The squeaky wheel is true in these places.

 

[Teacher Terry]

I am glad that some of you have had positive experiences.

 

[Walt34]

I am glad that some of you have had positive experiences.

Like any other facility the spectrum of care runs the gamut. My mother and DW's father were in excellent places, and the outcomes were about the best one could have hoped for.

My grandfather, sadly, had a far different experience. Being in high school at the time I didn't know the difference but I sure learned later. He was in a place where they essentially put him in a bed, gave him a remote for the TV, and waited for him to die. It didn't take long, who would want to live in those circumstances?

 

[Bamaman]

Like any other facility the spectrum of care runs the gamut. My mother and DW's father were in excellent places, and the outcomes were about the best one could have hoped for.

My grandfather, sadly, had a far different experience. Being in high school at the time I didn't know the difference but I sure learned later. He was in a place where they essentially put him in a bed, gave him a remote for the TV, and waited for him to die. It didn't take long, who would want to live in those circumstances?

We moved our 95 year old aunt from assisted living to full nursing home care. I'd go visit her and the lunch room was like a sea of blue hairs. Every one of them was in a wheelchair. They hired college students to wheel them in and document what they ate. What was rare was to find a man resident there.

But they did make those that were not completely bedridden get up, dressed and to meals. And they had social directors that were awfully good to the residents. When my aunt passed at 99 years and 9 months, the staff was incredibly kind to her.

 

[youbet]

My theory is that the facility wanted to keep him for the 21 days that Medicare would pay for rehab..

Could there have been a liability issue involved?

Also, could your friend have walked out (or been wheeled out by you or someone) without an official release form signed by the doc? That is, would they have physically restrained him? I'm just wondering if the doc was trying to avoid signing a form officially releasing him as being fully OK to leave while not having specific knowledge of the services that he would be getting going forward.

Not trying to defend the doc. Just wondering about the term "released." Is it "released" as in released from prison. Or "released" as in the doc says he's healthy enough to go and return to whatever he was doing beforehand and assumes some liability for signing off.

Did you try having the facility he was returning to contact the doc who didn't want to release him and sign off on taking full responsibility going forward?

 

[RetMD21]

Mil had a good stay post surgery last year. She needed the help and rehab and the hospital didn't fight her over returning to her CCRC. I think in her little corner of the world the hospital has given up on that at least for folks in CCRC.

The big bucks from Medicare are in the first few weeks of the stay. WSJ ran an article a few years ago showing discharges correlated with maximal billing more than one would expect by chance.

My cousin and uncle were confused that he was told he needed rehab post cardiac hospitalization. They couldn't see the point and didn't see any change and then as the 3rd week approached the facility decided that he had achieved some goal and discharged him back to his assisted living. No harm other than cost to medicare.