Botched hospital discharge-rehab needed

[bevette]

My 84 year old mother was hospitalized for 5 days for myopathy. The change in her abilities pre and post stay is staggering.

Prior to her hospital stay, she was completely independent, only needing a cane for balance. Since discharge, she has been mostly bedridden. With a walker she can go 10 steps before needing to sit. She is unable to get up from a seated position without assistance. Standing for any period of time is out of the question.

On discharge day, a social worker stopped by her room and handed me a flyer for a medical rehab clinic. She said I was to call the clinic when I got home to arrange for in patient rehab. That’s what I did and was told that wasn’t how it works, that a doctor order and social work recommendation is required to admit her. She received neither of these in writing.

She was seen by 5 different docs in the hospital as they were trying to diagnose her issue. The hospitalist was obviously a locum tenans doc as he has no evidence of existence associated with the hospital and therefore no contact info. The social worker’s name isn’t on the discharge papers (kicking myself for not writing it down). I was told the hospital usually calls within a day or two of discharge to check in but of course that hasn’t happened either.

My ignorance caused this terrible situation we find ourselves in. Does anyone with knowledge or past experience have any advice on how to obtain a social work rec and doc order requirement after a hospital discharge?

 

[MRG]

I'd be talking with the administration staff about what news agencies are on your list to communicate this story to.

Good luck and best wishes.

 

[ivinsfan]

I'd be talking with the administration staff about what news agencies are on your list to communicate this story to.

Good luck and best wishes.

For what reason, the OP needs help not to annoy people...I'm only familiar with outpatient cardiac rehab which is done in another location. There should be number that the hospital lists for rehab department. I suggest you call there and ask them to help you with the necessary paperwork. For my DH cardiac rehab I was told they would contact us. Cardiac rehab contacted our local doc who wrote the rehab order.



Also in our county there is in home rehab for those not able to safely leave their homes. Good luck, sometimes it does seem overwhelming. As far as MRG s advice there is zero upside in warring with rehab facilities, something has slipped thru the cracks most likely you can get it sorted by being nice.


Reading thru your post again, I can't figure out where your Mother actually is..where was she discharged to.

 

[pacergal]

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

 

[ivinsfan]

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

In our area the facility you are admitted to after leaving the hospital would coordinate this. But the OP doesn't say where her Mom is...

 

[YakGrl]

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.

 

[Sarah S]

I wondered about that too but apparently not https://www.medicare.gov/coverage/inpatient-rehabilitation-care

 

[youbet]

She was seen by 5 different docs in the hospital as they were trying to diagnose her issue. The hospitalist was obviously a locum tenans doc as he has no evidence of existence associated with the hospital and therefore no contact info. The social worker’s name isn’t on the discharge papers (kicking myself for not writing it down). I was told the hospital usually calls within a day or two of discharge to check in but of course that hasn’t happened either.

Does your mother have a PCP and was he/she involved with the hospitalization?

It doesn't sound like your mother can live alone at this stage. Have you begun to think through the situation if she will need to be in a NH?

 

[RetiredHappy]

OP's mother qualified for the minimum 3 days' stay in the hospital. It sounds like she was discharged home and advised for home PT. She should have been discharged with an order for Home Health Agency. The Home Health Agency would send out a RN to evaluate/open the case and order home PT, home health aide services and whatever else is necessary. Go back and talk to the hospital discharge planner for an order.

If OP prefers mother to go to a rehab/SNF, it should also have been discharged directly to a rehab/SNF.

Personally, I would choose to be discharged home rather than a rehab place if I have the money to pay for home care to supplement home health. Rehabs/SNFs are very germy places.

 

[youbet]

It sounds like she was discharged home and advised for home PT.

But OP said:

She said I was to call the clinic when I got home to arrange for in patient rehab.

 

[RetiredHappy]

But OP said:

I read it that she was discharged home, and advised to go to rehab/pt clinic as an outpatient. Much like I have sprained a muscle or after knee replacement, I go to a pt place.

 

[youbet]

I read it that she was discharged home, and advised to go to rehab/pt clinic as an outpatient. Much like I have sprained a muscle or after knee replacement, I go to a pt place.

Well, for what it's worth, she said "in-patient."

She said I was to call the clinic when I got home to arrange for in patient rehab.

 

[LateToFIRE]

I had something similar happen with one of our parents a few years ago - hospital discharged to home care when clearly was in no condition to be discharged. After a few frantic phone calls, after we realized our mistake, the best advice we got was to contact the hospital and inform them that they had made an "unsafe discharge." They sent a nurse to evaluate the patient. The nurse then instructed us how to call EMS and have them transport our parent to the emergency room (with us following), and have them evaluated. From there they were readmitted (which also restarted some sort of Medicare reimbursement clock for the hospital). We think they were discharged because of some kind of Medicare time-limit.

We were told to use very specific language with the hospital and EMS (wish I could recall more precisely) to make sure we would get their attention. Apparently, this happens A LOT. Apparently, the trick is to know the key phrases to use that essentially place a burden of LIABILITY on the folks you need to act on your mom's behalf.

 

[ivinsfan]

I read it that she was discharged home, and advised to go to rehab/pt clinic as an outpatient. Much like I have sprained a muscle or after knee replacement, I go to a pt place.

Or I read it as call the rehab clinic to set up the days and time of rehab...either way the paperwork needs to start with a PCP referral. which would begin with either the social worker or the referring doctor.

 

[ivinsfan]

I had something similar happen with one of our parents a few years ago - hospital discharged to home care when clearly was in no condition to be discharged. After a few frantic phone calls, after we realized our mistake, the best advice we got was to contact the hospital and inform them that they had made an "unsafe discharge." They sent a nurse to evaluate the patient. The nurse then instructed us how to call EMS and have them transport our parent to the emergency room (with us following), and have them evaluated.

We were told to use very specific language with the hospital and EMS (wish I could recall more precisely) to make sure we would get their attention. Apparently, this happens A LOT.

I dunno I'm sure it does happen sometimes... I've seen people who live alone get discharged to inpatient rehab solely because they live alone or can't get a relative or friend to stay with them. I've also seen people who insisted they were fine to go home sent to inpatient rehab. I think providers get a pretty good idea of what's going on.

 

[LateToFIRE]

I dunno I'm sure it does happen sometimes... I've seen people who live alone get discharged to inpatient rehab solely because they live alone or can't get a relative or friend to stay with them. I've also seen people who insisted they were fine to go home sent to inpatient rehab. I think providers get a pretty good idea of what's going on.

In our case, once we understood how the system works, it was clear that the hospital made the discharge decision more based on economics than patient care (i.e. Medicare reimbursement management), thereby endangering our parent. Unfortunately, the only language they understand is LIABILITY. I'm not knocking the medical professionals - they are most often doing the best they can in an extraordinarily corrupt system. But, corrupt it is.

 

[ivinsfan]

In our case, once we understood how the system works, it was clear that the hospital made the discharge decision more based on economics than patient care (i.e. Medicare reimbursement management), thereby endangering our parent. Unfortunately, the only language they understand is LIABILITY. I'm not knocking the medical professionals - they are most often doing the best they can in an extraordinarily corrupt system. But, corrupt it is.

Well that's not acceptable. We live in a great state for medical care and I've always seen staff put the welfare of the patient first.

 

[RetMD21]

In our case, once we understood how the system works, it was clear that the hospital made the discharge decision more based on economics than patient care (i.e. Medicare reimbursement management), thereby endangering our parent. Unfortunately, the only language they understand is LIABILITY. I'm not knocking the medical professionals - they are most often doing the best they can in an extraordinarily corrupt system. But, corrupt it is.

Usually the hospital has a deal with one or more SNFs for direct transfer. It is mutually beneficial since the post acute hospital payment to the "rehab" facility is good

 

[YakGrl]

I had something similar happen with one of our parents a few years ago - hospital discharged to home care when clearly was in no condition to be discharged. After a few frantic phone calls, after we realized our mistake, the best advice we got was to contact the hospital and inform them that they had made an "unsafe discharge." They sent a nurse to evaluate the patient. The nurse then instructed us how to call EMS and have them transport our parent to the emergency room (with us following), and have them evaluated. From there they were readmitted (which also restarted some sort of Medicare reimbursement clock for the hospital). We think they were discharged because of some kind of Medicare time-limit.

We were told to use very specific language with the hospital and EMS (wish I could recall more precisely) to make sure we would get their attention. Apparently, this happens A LOT. Apparently, the trick is to know the key phrases to use that essentially place a burden of LIABILITY on the folks you need to act on your mom's behalf.

This is what I was speaking about. Unsafe discharge should not be allowed but if the discharge social worker doesn't review the case carefully they can make the wrong decision on if the the patient can handle home care or needs full time inpatient rehab. They also discuss the situation with elderly sick patients who sometimes can't make good decisions or provide clear answers. The elderly sick patient just says they "want to go home" and don't realize that they are not able to care for themselves.

Sorry if I am going on too much but I have spent a lot of time dealing with this repeatedly and when I have been defending my relatives in this situations I have seen others in the hospital with no advocate be put in very bad situations.

 

[bevette]

OP here. Thank you all for the suggestions. To clarify, my mother was discharged to her home.

I called every physician who saw her. They were listed in her discharge papers. Only one replied, and he said that rehab orders must come from the attending hospitalist and social worker. The hospitalist has ignored all my calls. His number only has an answering machine. And there’s no social worker listed on paperwork.

I also called the rehab facility, but they are unwilling to contact a doctor on her behalf. They put the burden on us.

I toured an assisted living facility today for mom, and the salesman said the same thing happened to his mother several years ago when discharged from the same hospital. That might have been his attempt at an empathy sales pitch, but he seemed genuine.

 

[ivinsfan]

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

 

[joesxm3]

I am just guessing based on recent experiences with my mother.

I think the primary doctor can refer for SNF, but Medicare will not pay unless the patients comes from a three day hospital stay.

 

[ShadowBloom]

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

 

[pacergal]

I do hope your Mom gets the care she needs.
It sounds like the hospital really dropped the ball. Assisted in care rehab should always be a direct admit from hospital to rehab nursing facility. (at least in my nursing work history, you were only sent home if you could care for yourself. )

A few calls to your local congressperson and or Senate rep might be a good idea too, at some point.

 

[NW-Bound]

I do hope your Mom gets the care she needs.
It sounds like the hospital really dropped the ball. Assisted in care rehab should always be a direct admit from hospital to rehab nursing facility. (at least in my nursing work history, you were only sent home if you could care for yourself. )

A few calls to your local congressperson and or Senate rep might be a good idea too, at some point.

The bolded statement was the experience with my late father and father-in-law. The OP was unfortunate to have it all messed up. How to undo this?

My mother was in charge of the care of my late father, and as I recall there was a Medicare worker assigned to my father's case, because my mother talked of disputing with her often. If that's how it works, then Medicare can be involved to help?