My 87-year-old mother is in rehab after fracturing her pelvis from a fall. PT is going very slowly because her surgeon doesn't want her to put weight on the affected leg/side for 12 weeks. It's been about 7 weeks. Up until literally a few days ago, she was not cooperative with PT. She needs assistance getting in/out of a wheelchair, toileting, etc. As a family we are trying to figure out where she will be in 5 weeks at home, in AL, etc. Unfortunately, I live a 2 hour plane ride away. How can I work with the case manager to stay on top of her progress? My father is nearby to her, and visits daily, but light on details regarding what is going on in rehab. Do I need her to sign a form saying that I can have access to these progress reports? What do you recommend? I have to add, I am very grateful for the help offered here.
The most constructive thing to do might be to do some research about local care options, AL or NH (now you know the jargon). You can use the internet to get some ideas about what is available, and phone for brochures from where you are. Then if Dad gets in a mess, you are a few steps ahead. It’s a difficult time, whether you are locally based or far away. When you have more information, the people on the site may be able to help more.
On the top right of the screen for the site, you will see 'Care Topics'. Click on that, and you get an alphabetic list of many many topics that may help you come up to speed on the situation. On the screen you will also see a magnifying glass for searching. Type in ‘abbreviations’ to decode the language you are being forced to learn!
Best wishes, Margaret
Medicare will pay 20 days of rehab in full if patient is making progress.
Days 21-100 are paid by Medicare at 50%> Medicare supplement plans sometimes pick up the rest.
Again, IF the patient is making progress.
If dad can get them and then share them that might help.
If mom can sign a HIPAA form giving permission for you to obtain medical records that would work as well.
I assume she is a post hospitalization patient in rehab, so those requests to see if she might go to rehab are being done by a PT/ physical therapists. That - the PT - is who I’d suggest that you try to speak to directly and get them to tell you what forms they need to be in her chart to be able to speak w/you as to her abilities and likelihood to stay on rehab.
Her discharge paperwork from the hospital had all sorts of ICD-10 codes as to what her health conditions are and what rehab plan was to be; for postcare those have a preset “window” of time set by CMS to be a covered benefit for Medicare (fwiw other health insurance companies use these to determine coverage as well). Like Z47.1 is overall ICD-10 code for hip replacement aftercare.
So try to find her discharge paperwork from when she left the hospital, as would be helpful. Normally a set is given to whomever accompanies them upon leaving hospital. Also could be on line if the health care group uses an online portal. (e.g. EPiC does “My Chart”). Another set likely went to SNF rehab along with continuity of care transfer note. Lots of info on the web on how ICD-10 runs & how to “read” them.
PT reporting in her chart will in my experience realistically be the determining person(s) as to if she is “progressing” & sufficiently progressing for her health insurance to continue paying. Even though not supposedly should be doing any weight bearing on 1 side till wk 12, if she’s not doing other therapies, that will be in her chart. Medicare wants to be updated fairly frequently in order to continue to pay for her rehab stay. PT also sends their info & determination to MD who is the medical director of the SNF &/or to the initial requesting physician in her hospital discharge paperwork. The DON (director of nursing, who is kinda the goddess and ruler for residential care) should be cc’d with the forms you send the Therapist. But in my experience, until your mom exits being a patient in rehab totally neither the DON or the charge nurse for her floor really aren’t determining what’s happening for her care, as mom is primarily a rehab patient in the facility.
I’d be concerned that she won’t hit 12 weeks as becoming too far behind even now at 7 weeks. That she’s been “not compliant for care” till recently is in her chart. Medicare can & will cut off rehab ahead of MD orders.
So as a suggestion, you might want to read up on “gait training”. Is something PTs at a NH do for custodial care residents. It is billable to Medicare but not a rehab benefit. It’s part of a lawsuit settlement against CMS to provide for therapy to lessen loss of use. What happens often is those who enter a NH after hip break is they fail to progress to remain on rehab. Can’t return home or back to IL or AL as cannot do ADLs. So end up staying in the NH with a rehab unit BUT go from rehab patient on Medicare post hospitalization rehab health insurance coverage 2 BECOME a custodial care resident (private pay, LTC insurance or LTC Medicaid application filed for). & to keep them from ending up 100% bedfast, get “gait training”. This is - I’ll bet - what gets suggested for her. At 87, in rehab already 7 weeks & if mainly bedfast, going to be a beast to get strengthen all that was lost for almost 2 months plus walk on her own again. If not 100% motivated on her own to meet “progress”, rehab will end as they cannot force her to do PT exercises, etc.
You know your mom best if this is likely the path she will take. If so, if you like this place, easiest route is to let her stay; segueway from rehab patient to LTC resident on private pay initially. Then y’all figure out best for Dad to do as a community spouse & find a CELA attorney to help guide you all.
Also, there will be ONE person almost always with whom progress is discussed, and that will be at meetings as scheduled.
Speak with the Nurse manager to find out how all of it works at your own particular facility. Tell him/her what you told us about your interest in progress.
When my mother in law had non Hodgkin’s lymphoma she gave her oncologist permission to speak with her children and their wives.
My husband had the same problem as you are experiencing now. My father in law didn’t deal well with his wife’s health issues and he didn’t want to discuss her situation with anyone.
Nor was he good at explaining anything accurately. It was so much easier to get into from the medical staff.
Wishing you and your family well.
it will give her a few lines to add anybody she wants with their relationship to her..
it’s a simple form..