How the System Fails the Frail

MomPixieatConsulate
Mom with her grandog Pixie at the SNF that kicked her out because she couldn’t pay a month in advance.

Today for me was a lesson in how the long-term care system is failing.

Mom was home a little over 24 hours last week when she had to go back to the hospital. She became unconscious when we had her in the lift changing her Saturday evening. I had already had to call the paramedics on Friday, about 2 hours after she came home, because she slid out of her wheelchair and I couldn’t get her up.

She was discharged today to a Skilled Nursing Facility (otherwise known as a nursing home with a physical therapy department) for rehab.

After she was in the ambulance on the way to the SNF, the SNF received a Notice of Denial of Medical Coverage from Humana, her Medicare PPO. I got on the phone and filed an expedited appeal, which takes 72 hours.

Meanwhile, the facility admissions director was telling me that since she was coming in as private pay, I needed to go to the business office and pay for 30 days up front, or $8,280. I told her I couldn’t do that, but I would pay for a week up front to leave her there long enough for me to get things ready to bring her home.

I was standing in the social worker’s office, explaining the appeal and how it will take 72 hours, when the Executive Director came to the door. He’s a tall, burly man, with a crew cut, and a sour look. Standing in the hallway, he told me quite tersely that I needed to go to the business office and pay for 30 days. I told him I didn’t have that much, but could pay for a week. He said no. I asked him why, and he said, very rudely and loudly, “Company policy! If you do not pay for 30 days, she cannot stay! She has to leave now!” He was getting really loud. I was crying. People in the hallway and lobby were looking at us. I looked at the social worker and said I would take her home. He said, “Good!” and spun and left.

This was the same SNF she had been in just a week prior.  Her Humana Medicare PPO had required her discharge on Sept. 2, but I kept her there a week on private pay, to a tune of nearly $1,700, in hopes of winning an appeal.  I didn’t.  Ironically, I got word that my appeal was denied yesterday, too, just a couple of hours prior to this incident.  Had Humana authorized her to stay longer, she probably wouldn’t have ended up back in the hospital a little over 24 hours after coming home.

Apparently, Humana has given up on Mom — believing she can’t improve with rehab.  No matter that she walked with a walker prior to her first hospital admission on June 26.  Who would be able to get around well after spending the most of two-and-a-half months in a bed?

The ambulance company brought Mom home and put her in bed because I can’t transfer her from wheelchair to bed, etc. One of the aides I use works at the assisted living facility where Mom used to live, and is trying to rustle me up some extra help.

This is an example of how the system sets people up to fail. Denying her rehab means she will continue to decline. This is how people die. And this is how family caregivers have nervous breakdowns, have to quit their jobs, etc. Luckily, I have a job that is flexible with a company that “gets it.”

Something has to change. As our population ages, more and more of us will need help like Mom. And there are more and more of us to slip through the cracks of the system.

Be aware. Plan. Save. Most importantly, advocate for the frail.

Advertisements

Contact the author

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s