It happened again last week.
I received a call from a distraught daughter, Jean, whose mom had suffered a stroke and was in an acute care hospital. Her mom was quite ill, experiencing several complications of the stroke, and had lost much of her functional ability.
Jean had flown home from a business trip, her sisters were planning to fly in over the weekend, and her dad was spending all his time at the hospital. Jean had two young children at home and a husband who was also traveling. Her family was under a great deal of stress.
Jean had received a phone call that morning from a hospital-based case manager
. Apparently, the inpatient team had discussed her mom’s transition from the hospital to rehab and asked where she wanted her mom to go.
Jean was beside herself with anger and frustration:
How can “they” possibly be talking about my mom leaving the hospital? She’s still so sick!
What’s a case manager? I thought the doctor decided when a patient leaves the hospital.
Doesn’t insurance pay for 100 days in a hospital?
How do I know where she should go?
Can they just discharge her like that?
Many Common Misunderstandings
In these scenarios, there is a lot of information to assimilate in a very short time. The need for an appropriate plan of care intersects with Insurance/Medicare coverage and healthcare consumers who have never faced such a crisis may find themselves overwhelmed.
One common misunderstanding is the belief that individuals can stay in an acute care hospital for as long as the doctor wants them to.
In fact, there are certain criteria that any patient must meet to warrant an inpatient stay in an acute care hospital and for that stay to be covered by insurance. Some of those criteria are:
- The patient must be admitted to the hospital on the recommendation of a licensed practitioner with authority to admit patients.
- Medical records must contain sufficient information to justify admission and continued hospitalization. Detail is required to be sure that services are medically necessary, defined as, “Services or supplies needed for the diagnosis or treatment of a medicalcondition that meets accepted standards of medical practice.”
- Medical records must document the admitting diagnosis and be dated, timed and authenticated properly by the ordering or attending practitioner in accordance with state law and hospital policies.
In terms of the discharge decision itself, physicians make recommendations as part of a team. Their responsibility is to outline an appropriate plan of care for the condition at hand, but they also need to be knowledgeable about the criteria that must be met for an inpatient stay — and work within those parameters.
In an inpatient environment, physicians work alongside case managers who have responsibility for working with an individual and family to plan for discharge. Discharge plans usually fall into one of the following categories:
- Discharge to home with no assistance; follow-up with their doctor as an out-patient
- Discharge to home with in-home services
- Discharge to an acute rehab setting for continued care
- Discharge to a skilled nursing facility (SNF) for short-term rehab
- Discharge to a long-term care facility (nursing home)
The first two categories are self-explanatory. It’s the last three that are confusing.
When an individual remains ill and requires the continuous oversight of on-site physicians and nurses, 24 hours a day, an acute rehab setting can be the next step. In such facilities, patients not only receive medical and nursing care, but they also receive rehabilitation services from physical therapists, occupational therapists, and speech therapists.
One requirement to be in such a facility is that the patient needs an intensive rehabilitation therapy program, generally consisting of three hours per day of therapy, at least five days per week.
The transition to a skilled nursing facility may occur following a stay in an acute care hospital or an acute rehab setting.
In an SNF, physicians provide oversight but are not on site 24 hours a day. Nursing care, PT, OT and speech therapy is available, and patients are required to participate in rehab for 1-1½ hours per day.
If someone reaches a plateau and stops making physical progress toward measurable goals, or if a person is unable to participate in rehab activities at all, case managers will seek out family members and discuss plans for the next transition. Sometimes, that leads to a long-term care environment for “custodial
Strict Criteria Apply
In all non-home scenarios noted above, insurance/Medicare coverage is always dependent upon meeting specified criteria for a given level of care. Objective and measurable goals are set for demonstrated physical progress and must be reassessed constantly. In an acute rehab setting or skilled nursing facility, as with a hospital stay, a case manager begins preparing for the next transition immediately upon admission.
As for coverage duration, families are often surprised to learn that “100 days of coverage” is not a guarantee, but rather a maximumnumber of covered days in a skilled nursing facility if one meets the required criteria along the way.
In an acute care hospital, original Medicare covers up to 90 days per benefit period and offers an additional 60 days of coverage with a high coinsurance. The 60 reserve days are available to you only once during your lifetime.
In all circumstances, one must meet the required criteria.
I know firsthand how stressful emergency situations can be.Family members who experience an acute hospitalization with a loved one are bearing great responsibility to support and advocate on their behalf. And, because these events are never planned, they require everyone involved to learn a great deal in a very short time.
Expect and ask for the information you need by developing open and positive relationships with all involved. The health care professionals you encounter desperately want to teach and assist, even when it may not feel that way.
The more you know and understand, the more qualified you will be to take control in these difficult circumstances.