Our 91 yr. old mom is back in hospital but they coded it observation rather than admission. From what I understand, if she's 'under observation' it's not covered by Medicare? She had fallen and ER originally just did an X-ray that showed a cracked pelvis bone. Upon a return visit to the ER by ambulance because of excruciating pain, they did a CT scan which showed not 1 crack but 4 fractures on the pelvic bone!
Many questions here, first off, why didn't they do a CT scan originally on a 91 yr old woman with osteoporosis? She can't be discharged to re-hab because she can't handle 3 hrs of PT per day so the next step is a care facility but because she was coded as 'observation' for 4 nights it would be self pay? From what we understand, she would have had to be 'admitted' in the hospital for at least 3 days before they would discharge her to a care facility and be covered by Medicare.
2nd question - what's the difference between being 'admitted' and being 'under observation'
Who should I contact about these questions of why just the x-ray and why she wasn't re-admitted but only under observation? What is the difference between 'admission' and 'observation'?
We are new to this. very thankful that both mom and dad are pretty healthy for 91 and this is the first real issue.
Thanks in advance and please ask for clarification as I'm not sure this has made sense.
Call the patient advocate and call them on their BS. Get her admitted.
They kept mom, actually started on physical therapy while in the hospital. Then released to a nursing home for skilled nursing rehab. Skilled nursing rehab is wonderful in helping to regain strength back. Do take advantage of skilled nursing rehab. The hospital actually asked me to register mom at the nursing home the day before arrival.
The nursing home sent transportation to pick mom up from the hospital. Then she was sent home in three weeks with home health care. Home health is covered by Medicare as well. It consists of OT, PT, nurse and aide. Take advantage of home health if offered. Every bit of therapy helps.
Be aware that Medicare only pays for a certain amount of days in the nursing home for rehab. Mom went a couple of days over so I am assuming we will pay for that out of pocket.
Mom has a supplemental insurance too, Humana gold plus.
The hospital did what was financially best for them, not what was medically best for the patient. It's a question of whether Medicare will pay for the hospitalization; they will be for an admit but not for 'observation.' And after a three-day admission rehab will be paid for up to 100 days. Appeal any decision the hospital makes and let them know you will not accept this lying down.
I really feel for Marigold's mom. Can't imagine what that is like for someone in their 90s!! Plus PT wasn't recommended, the bone just needs time to heal. It takes 6 weeks for bone to heal according to my doctors.
When in ER they put the papers for you to sign - We refuse saying "We are under emotional stress making sure Mom is ok". We will talk to the social worker in the morning. We get the smile of "O you know the system"
When we meet with the ER doctor we INSIST on making sure it is not for observation. We always know she will need rehab, and as someone has already stated, the longer your LO is in the Hospital or in Skilled Nursing the more rehab your LO needs.
https://khn.org/news/observation-care-faq/
You have to be in the hospital for 3 days (NOT COUNTING the day of discharge) and Medicare will pay up to 100 days rehab in skilled nursing facility and must show improvement. If they do not improve the SNF will discharge them and recommend nursing home which goes into Medicaid. A fractured hip can be fixed, but not the pelvis. With a fractured pelvis I doubt she will improve due to the pain and there are no medical interventions that can fix that so there is a possibility she may become permanently bed ridden as elder heal much slower.
When it comes to more complex pelvic fractures that in itself is life threatening due to damage to internal organs, but more minor fractures are left up to bedrest and physical therapy, which can take 12 weeks to heal. Pinning internal pelvis is very invasive surgery with much risk, but the surgeon would have to make that call.
Here is more information on pelvic fractures
https://www.cedars-sinai.org/health-library/diseases-and-conditions/p/pelvic-fracture.html
A single fall can be a "game changer" to permanent bedridden, and even impending death. That's why people do fall precautions including using walkers. Most falls occur when first getting up so people even use fall mats to help break the fall.
Some breaks are awful. Apparently, the femur bone is a tough one to recover from. At least for her it was. She kept thinking she was going home.
When I had mom’s care meeting with the social worker I mentioned how sweet her roommate was and how she was anxious to get back home the social worker said that she was a long term care patient. Does that mean she wasn’t ever going to be able to go home? I didn’t want to ask the social worker because I am not her family.
What happens if a person can’t recover from a broken bone? The lady was asking the nurses for pain shots.
Get Ombudsman and perhaps SW from Agency on Aging to advocate for full admission for proper care and pain management. Her medication/pain management, transfer needs, etc. need more than LTC facility can provide at this point.
About not being up to 3 hours of PT at skilled rehab. They may schedule 3 appointments a day, but start with simple range of motion, arm strength, and basic functioning like how to manuver into lift assist devices. Some is OT, not PT. Actually this should szart during her full hospital admission. Also PZ should come to her room as she is not healed enough for transport to PT room yet.
Let them know you will file a formal complaint with Medicare and Joint Commission on Hospital Accreditation if they give you push back.
They will try to get you/you LO to sign off on tranfer/discharge under fear of getting full bill for extra days. This is common practice, ignore it. There is a reason posting patient rights is the law. They were also supposed to give patient booklet and explain all her rights the day of her admission...but many wait. Same for Skilled Care Facility.
After she is safe and healing, I would still report the doctor and hospital to Medicare & Joint Commission, so they have record that this is happening. Then next time, next patient, they know it's happened before.
They are probably worried that complications will occur due to her age. If this happens while she is in the hospital, they Must continue to provide care until she is truly well enough to go to LTC. They want her out before thst happens.
A dear friend had a heart attack earlier this year. She was taken straight to OR when she arrived in ER. Stinking hospital kept her, but coded her heart attack admission through the ER as observation for a heart attack, and immediate heart surgery. Appalling!
Know Your Rights
Observation vs Inpatient
When the doctor tells you that they are going to admit your loved one to the hospital you need to ask “are they being admitted as an inpatient or observation?”
If the answer is inpatient there is nothing else you need to do. If your loved one is being admitted under “Observation” you need to be aware of some potential problems.
Observation Status is paid by Medicare Part B, while inpatient status is paid by Medicare Part A. Individuals who are enrolled in Medicare Part A, but not Part B will be responsible for paying the entire hospital bill if they are listed as “Observation” status.
When an individual’s status is “Observation” they may be charged for services that Medicare would normally pay for such a co payment for each outpatient service they receive, 20% of the Medicare-approved amount for most doctor services after the Part B deductible.
In order to get Medicare to pay for rehab in a long-term care facility the individual must be listed as an inpatient for three (3) midnight's. If your loved one’s status is “Observation” Medicare will NOT pay for their rehab; it will be an out of pocket expense.
Since March 2017, federal law has required hospitals to provide both oral and written notification to patients who are listed as outpatients or Observation Status for more than 24 hours that they are being admitted under Observation and are not being admitted as an inpatient. This is called the “Medicare Outpatient Observation Notice” or (MOON) and it must be given within 36 hours of admission to the hospital.
What Options do you have if I your loved one is admitted under “Observation?”
1. If the individual is still in the hospital:
a. Ask the doctor’s to help change their status to inpatient, only the doctor can change an individual’s status.
b. Use Medicare’s “two-midnight rule.” (Not to be confused with the (3) three midnight rule above.)This states that if their doctor expects the individual to require hospital care for at least two mid nights, the hospital should be able to admit the individual as inpatient.
c. Consider other resources for care such as: an inpatient rehabilitation hospital, home health care or, outpatient therapy. These do not require a three (3) day inpatient stay.
If the individual is no longer in the hospital: Medicare does not have an official method to appeal the Observation status at this time.
Question?? Does your mom have Traditional Medicare or an Medicare Advantage Plan? Many of the Medicare Advantage Plans do not require the three mid-nights to qualify for skilled care (therapy) in the long-term care (nursing homes).
This info helps!
Regarding pelvic fractures, they are reported by many of the patients I took care of to be extremely painful.
Not only are they reported to be painful but there is really no treatment except pain mgmt and rest. I don’t even think they would order PT while hospitalized. A pelvic fracture will limit movement due to pain.
I took care of many seniors with a fractured pelvis as a homecare nurse. There was nothing I could do for them except teach them pain control and maybe upper body strength exercises but not much else until the fracture heals. There is no rationale for sending them to rehab as usually these folks were independent prior to the fracture. In elderly folk bones can fracture spontaneously from osteoporosis. The pain is real.
Folks were rarely sent to rehab with a fractured pelvis because they can’t do PT or OT due to pain. Thus sent home with pain medications and order to rest.
Please bear in mind that now you will need to be vigilant with skin care and inspection for pressure ulcer formation due to being in one spot for too long. You may want to think Palliative care if your Mother doesn’t improve.
Lastly the best place to be is out of the hospital for an elderly person with a non fatal illness. An elderly person already has a weakened immune system and the chances of catching MRSA, c.diff & VRE, not to mention staph infections. Pelvic fractures are generally not fatal.
Very sneaky, that “observation” status. Truth told, one has to be pretty ill for hospital admission these days even for non Medicare patients.
I have never head of 3 hours PT. PT must be coming in several times a day. They are also looking at her age.. 91 with osteoporosis. Can you ask for 2 hours of PT done in spurts during the day? My friends mom has PT 3 times a day, for about 20 minutes at a time. It's usually not that long from what I have seen with my elders.
Does your family have a living trust? No need to answer here, just food for thought. DNR, POLST....
Maybe they are going to observe her to see if she gets infections? I am not sure, but it sounds very painful.
If they try to push her out to go home, ask for palliative care or Hospice evaluation. They can evaluate her for these services so you can get help at home, so they come to you instead of trekking mom to doctor appointments.
So right now she is in a facility that is making sure that she moves during the day. Not necessarily “PT“ but movement. From what we are understanding, there is no PT that will help a broken pelvis along, that the main objective is to keep her resting and comfortable but also moving so that pneumonia and/or blood clots don’t form.
Her tentative discharge date is Sept 4. She wants to be home, yet she is scared that she will have another melt down because of being so overwhelmed like she did when she was home before. She has come such a long way though, I don’t think that will be a problem. Dad would like to see her stay there as long as she can and we agree.
At this point, she is coping with such grace. She is still as clear as can be mentally, it is the physically that is what she’s dealing with. Again, thank you all for the answers. This forum has been a great resource for me and my family. I’m thankful for the shared experiences and encouragement and knowledge.
Home PT and OT and a nurse are already scheduled. Plus a home health attendant to come stay for a few hours several times a week to give dad a break.
Again, thank you for the answers and encouragement! Time and hard work on her part has done wonders.