My MIL is in a rehab facility and feels that she isn’t getting the care she needs. She just got there last Wednesday. We have yet to have her care team meeting. I feel as though we need to have that before we determine that’s she’s not getting her needs met. But in the event that we feel she needs to be elsewhere, is it challenging to move her? What steps do we need to take?
Here’s why & I’m assuming she’s on Original Medicare and she’s coming from a hospitalization to rehab & she has a decent secondary insurer, like BCBS: post hospitalization rehab is routinely covered by Medicare for 20/21 days at 100% and then at 80% afterwards for up to 100 days, IF and only if, she is needing additional days and is progressing in her ability. The 20% is usually paid by her secondary insurance.
The day she entered the facility, or the next morning, she was evaluated based on the ICD-10 codes she was sent over with. The codes are in the discharge notes. The PT, OT, ST all have guidelines as to what rehab “progress” is standard for the codes & Medicare requires the info to be notated & logged in. For rehab, ime it’s not so much a care plan meeting but more a progress review; they will let you know how’s she’s progressing or if she seems to be at a plateau for some or all ADLs that rehab is addressing. Like her ability to self feed or walk 10’. Right now she's still being evaluated & measured. I’d allow 5 days for her to show a pattern. She’s not quite yet at that point if she just got there on Wed.
However, Your MIL has to, HAS TO, make an effort in her rehab. If she tells the therapists she doesn’t want to do a session for whatever reason, they cannot & will not force her. They’ll say, “that’s fine, let’s try for later today or tomorrow”. But it will go into her chart as non-compliant for care. Give some thought as if this could be the case.
My Mil fell & broke her hip, got hospitalized and then onto rehab unit within a NH; she was all it hurts too much, maybe manana every day from her bed; not in a chair but lying in bed; she wanted to be waited on & coddled. LSS she was totally noncompliant for care, rehab stopped (actually didn’t truly start) and she became a long term care resident at the NH before her 21 days were over. She was quite upset that she needed a Walker & a wheelchair, she thought she was going to allowed to set her own pace for care & all would be just fine. Went from rehab patient (MediCARE) to LTC resident & applied for Medicaid. The rehab rules are strict. You know your MIL, if she is not actively & actually doing what shes asked to try to do in rehab, she’s toast. If you or her son need to be there daily cheerleading to get her to participate, and she’ll listen to you, do it. The first 21 days are critical for rehab.
On the “we determine… needs met”. The reality is that determination is not up to you. Her health chart determines what her care plan is. Right now it’s her discharge notes & rehab orders in her chart that are guiding her care plan, so it’s beyond important that she participates in rehab sessions. It could be twice a day PT and once a day OT. Should she become a LTC resident, the determination is done by the medical director MD who places orders which nursing staff does under the direction of the DON (director of nursing & is pretty much the power center in a NH). As her family & her POA, you of course have input in but do not have the final determination on her care plan. The only way around this would be a very rarified private pay 💰 💰 facility with huge staff that totally caters to its residents.
As long as the one you wish to send her to had a bed available.
Contact the one that you want her in and they can arrange the transfer.