I submitted a Medicare appeal for my father. SNF discharge with "plateau in therapy"! I will fight with everything I can for Dad! Advice?

I’m sorry your dad has such an overwhelming set of conditions. Each time my dad was hospitalized, he lost ground, and rehab only brought him to a new and lesser normal. Lying in a hospital bed is an enemy of the elderly with chronic health issues. Movement is sidelined and often never returns in the same way. My dad also made no progress in his last rehab, decided for himself to come home on hospice care, and died a bit over a month later. His medical conditions were overtaking the joy derived from life. This could be a possibility for your dad as well. It’s hard to work at, and want to be here in the face of so much bad health. I wish you both peace in navigating this

Thanks Igloo.

I don't think you understand what rehab is. The therapy is to help the patient in trying to get back to normal to be able to be sent home. Its not a cure. There comes a time when no amount of therapy is going to make a difference or make him stronger. Your Dad has a lot of health problems that contribute to him being able to walk or not. If he has plateaued there is no more they can do. His CHF alone will keep him from having the strength to do therapy. My Dad was given a stress test and they had to stop it. He just had no strength.

So sorry you are going thru this.

If he’s getting a hospice consult, that’s going to be slightly different than getting a needs assessment. If u are really really really considering having him leave the NH and moving into your home, I’d try to get both done. Hospice is an awesome Medicare benefit, but it is limited in scope and in actual realtime. The needs assessment can shed some insight into what all will be needed all the rest of the time. If he’s 24/7 oversight and on black box warnings drugs, he’ll need a big care team coming into your home & that understands & will deal with his meds appropriately. If the aides are ones you are hiring on your own, please check your insurance to see that you have coverage (you may need a rider) AND realize they are considered household employees by IRS so you or dad are responsible for doing FICA & all paperwork on taxes. If you use an agency, they deal with this aspect.

Hospice can be done either in home or can be a part of his being in a facility. But hospice alone will never provide all the care needed. Now hospice will provide some equipment.... like a special bed with pressure sensitive mattress, a geri chair, a wheeled geri bathing chair if you have an open floor shower area, order specific nutritional stuff if his diet requires that.

My mom was in a NH, fell (pulling her wheelchair on her way to arts & crafts no less), shattered a hip, became bedfast and went onto hospice, so the regular care team at the NH still did their stuff AND hospice came in 2 - 3 x a week for 3-4 hrs and between reg NH staff & hospice were moms bathing team, it was amazing to watch, meanwhile NH staff stripped the bed & put on new linens, hospice got her dried, moisturized & into new clothes and then helped with a meal or other comfort care. It was 3-4 pros doing stuff. My mom was tiny petite so never got pressure ulcers & pretty compliant & cognitive and even with all that it really was a 2 person job to efficiently get things bigger things done for her the 18 l...o...n...g months she was on hospice before she finally died. If your dads a big guy and wants to get up and do stuff but really is not ambulatory or cognitive enough, it’s going to be challenging to care for him on your own. I’d suggest you ask what his medications will possibly do for his cognitive ability. If he’s on fentanyl, pill or lollipops, clearly ask how the hospice deals with giving & storing his meds.

Sometimes, although rare, if they are very very ill and eligible for hospice, they can go into an in-unit hospice facility. Sometimes it’s it’s own wing in a hospital; sometimes it’s a separate freestanding building adjacent to a hospital (Kindred beds often falls into this category). MediCARE will cover it as extension of hospitalization benefit combined with hospice benefit. My MIL got pneumonia at her NH, went to ER, got hospitalized, became severely septic. She moved from the hospital into a free standing hospice facility; she had cascading organ failure atop sepsis and died abt 3 weeks after the move. MediCARE covered it. It was not the usual 2-3 times a week hospice benefit.

CrazyCatLady21

I just wanted to send you a great BIG hug. I feel your pain o, "very sad sad situations."

I think you’ll find that Jimmo is not applicable to your dads situation.

For those not familiar with Jimmo, it’s a 2013 settlement related to a class action Jimmo V. Sebelius. The Sebelius was Katherine Sebilius who was head of DHHS from 2009-2014, so she was the head of all things MediCARE. The plaintiff, Jimmo, was diabetic, legally blind, an amputee & on MediCARE. She had been receiving in-home health care & out patient therapy (aka OPT so skilled care done by PT, OT, ST) paid by Medicare. MediCARE had covered in home & OPT for her but stopped as MediCARE applied “improvement standard” for determining as to whether Medicare paid & Jimmo did not meet “improvement”. Jimmo was the lead plaintiff but the others were mainly MS & ALS. I’m familiar with Jimmo as I had a cousin who had secondary polio and he was on in-home & OPT, & the agency he used sent out notifications as to Jimmo and what that would mean for their clients.

Jimmo settlement requires Medicare to look at certain standards beyond “improvement” alone for claim determination; & those who can benefit for skilled services for maintenance or to prevent or slow decline or deterioration, then MediCARE beneficiaries are entitled to coverage.

CrazyCat, the issue, imho, will be that for your dad there is no “maintenance” for him to stay at. Your dad has had recent significant cardiac and cancer dx’s, continuing rehab at the SNF for him won’t change his prognosis or slow decline of his diagnosis. That’s why Medicare has declined coverage. It’s not a Jimmo thing.

Jimmo seems to be best used for those who
1. have a preexisting condition like MS, ALS, Parkinson’s, paralysis (like my cousin w Polio) as they need “maintenance” or other therapy to “slow or prevent decline”
AND
2. are getting skilled services in their home
For residents in a facility, they can use Jimmo to have Medicare pay for PTs to do “gait training” or for OTs to do hand movement therapy so they do exercises to work on keeping their ability to clench flatware or hold things so it slows their decline. My mom had gait training 2-3 times a week at her NH till she became bedfast. It’s pretty common for NH residents & it’s all paid by Medicare as it’s covered “maintenance” as part of Jimmo settlement; it’s not Medicare rehab coverage per se but Medicare coverage “to prevent further deterioration or preserve current capabilities”. To me, the issue will be for your dad is he likely does not have “current capabilities” to preserve and those PT notes show that is the case and why he had been denied.
He might be able to get a Medicare clock reset for day 1 moved to day 15 as no services provided during quarantine, but unless he’s meeting a need for rehab, he’s going to be discharged from rehab. Usually what happens is that they transition from being a rehab patient on Medicare to becoming a long term care resident on private pay, Medicaid or LTC insurance. That is likely what the facility will recommend.... unless family has told them they are moving their elder home no matter what.

This is all quite overwhelming to deal with. If you are set on having him move into your home, I’d suggest that you have a needs assessment done for him right now ASAP while he is still in a facility. It will tell you just how big of a care team you realistically will need. If it is 24/7 oversight, that means 3 sets of caregivers. You cannot do it solo. You may want to have him evaluated for hospice as that will bring in a care provider for a few hours maybe 2 or 3 times a week who will help with his medication management, vitals and bathing; hospice is a Medicare benefit.