The old man slept quietly as his daughter sat by his hospital bed. Suddenly, an aide walked in and announced that a move was imminent.
“Your time here is up,” Bonnie Miller Rubin remembers the aide explaining. “He’s going to a nursing home.”
It was 9 p.m., and Rubin’s 91-year-old father had been asleep for several hours. “I said, ‘Are you kidding me?’” Rubin recalled.
“I felt powerless,” she said, remembering her alarm on that cold night three years ago. “What rights did I have?”
In fact, Rubin could have filed a “fast appeal” of her father’s pending discharge with a Medicare Quality Improvement Organization. If she’d made a telephone call on the spot, her father would have stayed in the hospital until an independent physician reviewed his circumstances.
Every older adult admitted to a hospital as an inpatient has the right to challenge a discharge if he or she feels unprepared to leave. But few people understand the process that’s involved.
Frequently, seniors and their families are caught by surprise when a transfer from the hospital is at hand.
“People don’t understand how fast-tracked things get,” said Trish Colucci, a principle care manager with Peace Aging Care Experts in Flanders, N.J. “There’s enormous pressure on discharge teams to get patients out.”
After a lawsuit charging that Medicare was not giving beneficiaries adequate notice of the right to appeal pending discharges, the government issued new regulations on the process a decade ago. Here’s how so-called “fast appeals” are supposed to work:
Know your rights. Every older adult admitted to the hospital should get a written notice of their rights — including the right to appeal planned discharges — within two days. If you remain in the hospital for at least five days, you should receive a second notice before being discharged.
This “Important Message from Medicare” will give you the name and a phone number for your Medicare Quality Improvement Organization (QIO) — an entity charged with handling fast appeals as well as other matters, such as complaints about the quality of care.
QIOs serve older adults on traditional Medicare as well as seniors with managed care-style Medicare Advantage plans. Livanta is the QIO for seniors with Medicare who live in the Northeast and the West Coast. KEPRO covers the rest of the country.
Rubin doesn’t remember receiving these notices from Evanston Hospital, just outside Chicago, where her father was being treated for respiratory distress. But Jim Anthony, a hospital spokesman, said the medical center always distributes them, as required.
The medical center began planning the older man’s transition to a nursing home on “the day of admission, with the family’s knowledge,” Anthony explained.
The bottom line: Read all the documents that you’re handed in the hospital. Don’t assume you can put off doing so until later.
Initiating an appeal. If you don’t feel ready to leave the hospital, call the QIO and explain that you’re filing a fast appeal of a pending discharge. You can call during the day or at night up until just before midnight on the day that the discharge was set to occur.
If someone’s not manning the phones — QIOs are open 9 a.m. to 5 p.m. during the work week and 11 a.m. to 3 p.m. on weekends and holidays — leave a message explaining your situation.
A family member or caregiver can initiate the process if a patient is unable to do so. But they may subsequently need to fill out a form clarifying that they can act as the patient’s representative.
Only seniors admitted to the hospital qualify for this appeals process. Patients on “observation status” have a separate appeals process. So make sure you clarify your status often, this might not be clear.
Hold tight. Once a fast appeal has been lodged, you can’t be transferred from the hospital until its resolution. Usually, that takes about two days.
Nor can you be charged for the extra time you spend in the hospital, though coinsurance payments and deductibles will still apply.
The hospital will send a copy of your records to the QIO, to be examined by an independent medical reviewer. You have a right to see these documents, if you so choose. The QIO will contact you and inquire about your discharge concerns.
If the QIO determines that a discharge is appropriate, you can stay in the hospital until noon the next day, at no extra charge. If the QIO overrules the hospital, you can stay until another discharge is proposed.
The standard? Medical care in the hospital must be deemed medically necessary by your physician.
If you’ve stabilized, without symptoms such as a fever, difficulty breathing, or a purulent wound, you’ll probably be considered ready for transfer, said Anne Sansevero, a registered nurse and aging life care specialist in New York City.
Stay informed. It’s a good idea to ask your doctor every day “Is there any update on how long I’m likely to be here?” so you don’t find yourself “in a last minute situation,” said Liz Barlowe, a care manager from Seminole, Fla.
If the hospital hasn’t adequately addressed your need for a “safe discharge,” you may have grounds to contest its decision.
Barlowe described a 78-year-old client who fell and broke her hip when visiting her son and daughter. Preparing for surgery, scans showed that the woman had masses in her uterus and pelvis — cancer.
After hip surgery, hospital staff said they couldn’t bring in a gynecologic oncologist to consult on the older woman’s case, and recommended that she be sent to a rehabilitation center.
Barlowe immediately contacted KEPRO, which overturned the hospital’s decision. Instead, the QIO’s medical reviewer directed that the patient stay there until a cancer specialist provided a consultation and helped to devise a plan of care.
The QIO’s intervention bought the family another 48 hours, during which time they were able to find a facility in Miami able to offer chemotherapy as well as rehabilitation for the woman’s hip. And the patient was able to rest and build up her strength.
Fast appeals similarly exist for hospice, home health, skilled nursing and rehabilitation services, but the rules and time frames involved differ slightly.
KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.
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In 2011, President Obama proclaimed November as National Family Caregivers month to “pay tribute to the individuals throughout America who ensure the health and well-being of their relatives and loved ones.” The proclamation honors “the tireless compassion of Americans who heal, comfort, and support our injured, our elders, and people with disabilities. This month and throughout the year, let the quiet perseverance of our family caregivers remind us of the decency and kindness to which we can all aspire.”
As a society, it’s easy to pay lip-service to the folks in the trenches of caregiving. Why wouldn’t the nation honor the 40 million family caregivers in the U.S. who, in 2013, provided an estimated 37 billion hours of assistance to an adult with activities of daily living? According to the AARP, the estimated economic value of their unpaid contributions was approximately $470 billion in 2013.
But even the words “tireless” and “quiet perseverance” connote martyrdom, sacrifice and isolation. These attributes don’t always make the best caregivers and they devalue the all-important first rule of caregiving, which is to ask for help. This year’s theme is, Take Care to Give Care, acknowledging the fact that caregiving, while rewarding, is physically and emotionally demanding. By virtue of a caregiver’s role, the caregiver is at a higher risk of health issues.
Caregivers, celebrate yourself this month by recognizing the need to Take Care to Give Care, in whatever way makes sense to you. In the words of a fellow caregiver, “I’ve become very good at asking for help, in putting necessity first and pride last.” Successful caregiving takes a team. Know your capabilities. Spend time putting a network of support in place, to have people you can call on in an emergency. People around you likely want to help, but they need to be told specifically what type of help you need and when you need it.
Some additional reminders from the Caregiver Action Network:
- Caregiving can be a stressful job. Most family caregivers say they feel stressed providing care for a loved one. With all of their caregiving responsibilities – from managing medications to arranging doctor appointments to planning meals – caregivers too often put themselves last.
- The stress of caregiving impacts your own health. One out of five caregivers admit they have sacrificed their own physical health while caring for a loved one. Due to stress, family caregivers have a disproportionate number of health and emotional problems. They are twice as likely to suffer depression and are at increased risk for many other chronic conditions.
- Proper nutrition helps promote good health. Ensuring that you are getting proper nutrition is key to help maintain your strength, energy and stamina, as well as strengthening your immune system. Maintaining a healthy diet is one of the most powerful things you can do to take care of yourself and keep a positive attitude overall.
- Ensuring good nutrition for your loved one helps make care easier. As many as half of all older adults are at risk for malnutrition. Good nutrition can help maintain muscle health, support recovery, and reduce risk for re-hospitalization – which may help make your care of a loved one easier.
- Remember: “Rest. Recharge. Respite.” People think of respite as a luxury, but considering caregivers’ higher risk for health issues from chronic stress, those risks can be a lot costlier than some time away to recharge. The chance to take a breather, the opportunity to re-energize, is vital in order for you to be as good a caregiver tomorrow as you were today.
From the Aging Life Care Consultants at Elder Care Consulting
Older people are not only taking more drugs, they are also taking more over the counter preparations.
Many over the counter supplements touted to improve health are in fact dangerous when mixed with some medications.
In a study published in the Journal of Internal Medicine, two- thirds of older adults were using dietary supplements which included vitamins and herbs.
Some of these products, even those that sound natural, may interact with medications.
In fact, a study of interactions in 2010 found that 15% of the individuals had a major drug reaction.
Some of the more common include:
- Fish oil, vitamin E, Coenzyme Q10 when taken with Coumadin may increase bleeding risks.
- Saw Palmetto, popular for benign prostate enlargement, should be used with caution with medications prescribed for prostate.
- Melatonin, a natural hormone that helps to regulate sleep/wake cycles, should be avoided with antihistamines or muscle relaxers.
Tips for people taking medications:
- Use the same pharmacy for all your medications and inform them of any over the counter medications you may be taking.
- Take your list of medications, including supplements, to all your physician appointments.
- Evaluate the benefit and risk of any medications or supplements taken together.
- Do not use outdated medication or medications borrowed from your friends.
It is important to remember that the best way to reduce a possible drug interaction is to cross check your medication and supplements with a local pharmacy. They have the ability to run the profile through a computer system for a medication interaction check.
Lori O’Connor, MSN, APRN, is a national certified Professional Geriatric Care Manager with Elder Care Consulting, LLC.
For more information contact us at www.eldercareconsultingllc.com 860-643-9500.
The third Wednesday of each month starting May 18, 2016 from 5:30 to 6:30 pm
Please come visit the Elder Care Services Booth featuring Elder Care Consulting, Elder Care Associates and Senior Moments at the 2016 Tolland County Business Showcase on Tuesday, April 5, 2016 from 4:00 to 7:00 pm at Maneeley’s Banquet Facility, 65 Rye Street, South Windsor, CT. Check out the wonderful crafts by our Senior Moments Clients and be sure to enter our drawing for a Shady Glen Gift Certificate!