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My mom needs skilled nursing now! My 91-year old mother has a stress fracture in her back due to osteoporosis. She is in pain most of the time and can't walk. She requires much more help than her assisted living facility can provide, and yet the facility will not allow her to transfer into their skilled nursing wing until she's been in the hospital for three days. She doesn't need hospital care! She lives with my 100-year-old father who is trying to take care of her at his own peril. It's a catch 22 situation that is a tragedy waiting to happen, but her facility turns a blind eye to her predicament. Medicare requires a 3-day hospital stay to be admitted to skilled nursing. She doesn't need to be hospitalized! She only needs skilled nursing. How can I get around the Medicare requirement so my mother can get the care she needs? I'm not sure what to do and would love to get some advice. Thank you.

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Does the skilled nursing facility (SNF) have long-term beds and are any Medicaid certified and available? If so, then Medicaid should be applied for immediately (there is no 3 day hospitalization requirement for Medicaid nursing home benefits). The family may have to pay privately until approval but benefits will be retroactive to the first of the month if otherwise medically and financially eligible. Once Medicaid pays the facility the facility will reimburse the family.

If there are no funds for SNF private pay the facility may accept her "Medicaid pending". They will want to see all financials and will probably want to do the application themselves. If there are asset/income issues they most likely will not do the application and may not offer a Medicaid pending option.
If transfer to the SNF is not possible near term I suggest:

1. Apply for Medicaid immediately. Nursing home benefits can be applied for even if the applicant is not currently in a SNF. If assets/income are an issue consult a Medicaid specialist or attorney for guidance.
2. Ask your mother's physician for a prescription for Medicare skilled home care benefits. She will receive therapy in the ALF and will receive some minimal home health aide services.
3. If funds are available hire a part-time private home health by the hour to assist your mother and father until Medicaid approval.
4. Contact a Hospice organization in your area that provides "Palliative Care". This is NOT end of life care. Don't be stigmatized by the word "Hospice". This can be a tremendous benefit and is paid for by Medicare.
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According to Medicare, Part A will pay part of the costs for a stay in a NH IF:
"the patient must have been in "impatient status" in a hospital at least three consecutive days, not counting the day of discharge... Three midnights is a good rule of thumb." this is from the Medicare binder sitting on my desk. I'm a SHIP counselor. SHIP being Senior Health Insurance Program.
It's not the assisted living rule. It's a Medicare rule.
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Tell your Dad to push the call button when Mom needs help. If he pushes that button often enough, the facility will realize there is a need.
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Easy

Skilled nursing wants to know what is going on with your mom, before they get involved. Before transfer, hospital will brief whatever facility she is going to to assess her needs,then the ball, so to speak, will be in the skilled facility's hands.
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When my father had pneumonia he was not in the hospital long enough to qualify for Medicare to pay for SNF, however we were able to check him into the same facility for rehab as a private pay patient. He paid for the room, but Medicare picked up the tab for his OT, and PT.
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I found out the hard way a few years ago that my Mom's hospital stay was not as long as I thought. The first 2 days they listed her as an "Observation" patient before they actually admitted her. After admission the 3 day clock started. Best of luck with your parents.
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Every time I took my mother to the hospital they kept her the required time. It is a 5 day wait here. Once was for a urinary infection, once for pneumonia, and once because we wanted a feeding tube because she wouldn't eat or drink. Why is she pushing the call bell? What symptom does she have?. The hospital stay is to get her evaluated, not that she needs to stay there. There is obviously something going on. Let her go to the hospital.
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Thanks for your helpful comments. I'm thinking I need to get an eldercare representative to help us with the issue of providing the right care for my mother. It seems the assisted living facility Mom and Dad are in would be able to take the lead on my Mom's care and inform us about options. They only ask her if she wants to go to the hospital if she pushes the call button too much. My sister and I are at a loss of what to do. We're no experts on eldercare.
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It all hinges on the fact that the patient has to wait for a Medicare bed in the SNH to become available. There are a certain number of Medicare beds set aside in the SNH.
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just to echo dmasty: My husband was kept in the hospital after an ER visit for three whole days, but apparently wasn't considered to have been in the hospital from the standpoint of Medicare follow-up skilled nursing or home health care, because he wasn't "admitted". (You could have fooled me; there he lay, in the bed, with nurses running around etc.) I found out after the fact that he was only there for "observation". Nobody at the hospital thought to inform me of this. It turned out okay, because they sent him to a memory care unit from the hospital and that wouldn't have been paid for anyway. But if you are counting on the post-hospitalization Medicare benefit, insist that Mom be ADMITTED to the hospital and stays there for the minimum 3 days. I too think that her ALF is at least partly trying to get you the Medicare benefit. Also, why not let Mom go to the hospital and enjoy it? She should get the care she needs and it will take the burden off Dad.
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