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Old 09-30-2015, 11:06 AM
 
Location: Wisconsin
16,856 posts, read 17,163,830 times
Reputation: 40667

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If you have followed my recent saga in "Vent! ARRGGG! Vent" thread you know that my husband (previously disabled with brain damage) fell down a flight of stairs and suffered a subdural hematoma on September 4th, was in the hospital, including hospital rehab, for three weeks and was out for four days & has now been readmitted to the hospital. He had just started outpatient rehab at a special place that deals with head injuries.

I spoke with his primary care physician this morning and she feels that a nursing home (at least temporarily) may be the best place for him. She knows how difficult it is to care for him as well as how long I have been his primary caregiver, with very limited support.

Does anyone know the rules for Medicare coverage for a nursing home stay after a patient was released from a first hospital stay and is then readmitted to the hospital? Do they have to be stay another three days? Before I talk with the social worker/discharge people it would be helpful to have information from others who have gone through this before.

Thank you.
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Old 09-30-2015, 11:28 AM
 
3,758 posts, read 10,587,193 times
Reputation: 6684
First off - official link:

https://www.medicare.gov/Pubs/pdf/10153.pdf

From the publication, page 17 - Item 2: "When will medicare cover SNF care":

"You have a qualifying hospital stay. This means an inpatient hospital
stay of 3 consecutive days or more, starting with the day the hospital
admits you as an inpatient, but not including the day you leave the
hospital**. You must enter the SNF within a short period of time
(generally 30 days) of leaving the hospital.
After you leave the SNF, if
you re-enter the same or another SNF within 30 days, you may not
need another qualifying 3-day hospital stay to get additional SNF
benefits. See item 5 on page 18. This is also true if you stop getting
skilled care"

So, its possible that his original hospitalization would be sufficient. However, you'd probably want to call medicare and confirm that. Additionally, I'm assuming they are wanting him to go to SNF (skilled nursing facility) for rehab of some kind? Medicare will cover that (if their requirements are met). Medicare will not cover custodial care (i.e. no skilled therapy required, but assistance with daily living activities is needed) - which is typically what a "nursing home" does.

(i.e. people who can't feed themselves, can't bathe themselves, but don't require physical/occupational or speech rehabilitation. (Because they've already passed the chance at recovery, normally).

I hope his rehospitalization was not too serious and that he's able to get some help in a good facility, and that you're able to get that stay covered.
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Old 09-30-2015, 01:57 PM
 
Location: Wisconsin
16,856 posts, read 17,163,830 times
Reputation: 40667
Quote:
Originally Posted by Briolat21 View Post
First off - official link:

https://www.medicare.gov/Pubs/pdf/10153.pdf

From the publication, page 17 - Item 2: "When will medicare cover SNF care":

"You have a qualifying hospital stay. This means an inpatient hospital
stay of 3 consecutive days or more, starting with the day the hospital
admits you as an inpatient, but not including the day you leave the
hospital**. You must enter the SNF within a short period of time
(generally 30 days) of leaving the hospital.
After you leave the SNF, if
you re-enter the same or another SNF within 30 days, you may not
need another qualifying 3-day hospital stay to get additional SNF
benefits. See item 5 on page 18. This is also true if you stop getting
skilled care"

So, its possible that his original hospitalization would be sufficient. However, you'd probably want to call medicare and confirm that. Additionally, I'm assuming they are wanting him to go to SNF (skilled nursing facility) for rehab of some kind? Medicare will cover that (if their requirements are met). Medicare will not cover custodial care (i.e. no skilled therapy required, but assistance with daily living activities is needed) - which is typically what a "nursing home" does.

(i.e. people who can't feed themselves, can't bathe themselves, but don't require physical/occupational or speech rehabilitation. (Because they've already passed the chance at recovery, normally).

I hope his rehospitalization was not too serious and that he's able to get some help in a good facility, and that you're able to get that stay covered.
Thanks for your post. I also found that passage on-line about going into the SNF within the 30 days of release, however, since he already had hospital based rehab for the original fall I wasn't sure if that applied to him. He was/is scheduled for outpatient therapy at a facility/program that specializes in head injuries.

I'm at the hospital right now and will be talking with the social worker soon.
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Old 09-30-2015, 04:59 PM
 
Location: Wisconsin
16,856 posts, read 17,163,830 times
Reputation: 40667
The social worker said that SNFs in my area may or may not accept my husband. It depended on if they felt that Medicare would pay or not. It seems odd to me - wouldn't the hospital doctors or therapists decide if he needed more rehab?
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Old 09-30-2015, 08:04 PM
 
Location: SW US
2,200 posts, read 2,014,533 times
Reputation: 3766
I think if it has to be paid for by Medicare, unfortunately, the doctors have to defer to Medicare's rules.
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Old 09-30-2015, 08:07 PM
 
2,473 posts, read 2,508,994 times
Reputation: 4302
You are correct about the admission to the nursing home for rehab within 30 days of discharge from the hospital.

Perhaps the social worker simply meant the facility would review his medical record and decide if they can meet his need, and if he can participate in therapy. Their therapists would be part of that review, and therapists tend to be an optimistic bunch. It's standard practice.

The social worker is wise not to promise anything.
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Old 09-30-2015, 08:12 PM
 
Location: Wisconsin
16,856 posts, read 17,163,830 times
Reputation: 40667
I just spent the last two hours on-line comparing nursing homes. The difference in ratings is absolutely shocking. One SNF in my immediate area had 20 stars out of a possible 20 stars (much above average in all areas) and a few others had 5 or 6 out of 20 stars (well below average) Yikes!

Keep your fingers crossed that one of the better SNF has a bed and believes that my husband qualifies for rehab.
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Old 10-01-2015, 06:44 AM
 
3,758 posts, read 10,587,193 times
Reputation: 6684
Fingers crossed.

Unfortunately, I'm not a great believer in the ratings, because I've seen pretty crappy care and facilities with decent ratings. But, you're right - you don't want to go to the bottom of the barrel if you can help it.

Best of luck!!
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Old 10-01-2015, 08:21 AM
 
15,254 posts, read 16,751,013 times
Reputation: 25411
Quote:
Originally Posted by germaine2626 View Post
I just spent the last two hours on-line comparing nursing homes. The difference in ratings is absolutely shocking. One SNF in my immediate area had 20 stars out of a possible 20 stars (much above average in all areas) and a few others had 5 or 6 out of 20 stars (well below average) Yikes!

Keep your fingers crossed that one of the better SNF has a bed and believes that my husband qualifies for rehab.
Fingers crossed.

I think the most important factor in your husband getting good care in an SNF is your being present. You don't have to be there all day, but you need to come and go at different times. Chat up the nurses, be friendly, keep your eyes open.

It's sad that you can't trust the staff to always do the right thing, but frankly, you can't. They're overworked and underpaid and sometimes they just don't care.

Good luck with all of it.
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Old 10-01-2015, 10:25 AM
 
20,230 posts, read 16,430,675 times
Reputation: 37944
Quote:
Originally Posted by germaine2626 View Post
If you have followed my recent saga in "Vent! ARRGGG! Vent" thread you know that my husband (previously disabled with brain damage) fell down a flight of stairs and suffered a subdural hematoma on September 4th, was in the hospital, including hospital rehab, for three weeks and was out for four days & has now been readmitted to the hospital. He had just started outpatient rehab at a special place that deals with head injuries.

I spoke with his primary care physician this morning and she feels that a nursing home (at least temporarily) may be the best place for him. She knows how difficult it is to care for him as well as how long I have been his primary caregiver, with very limited support.

Does anyone know the rules for Medicare coverage for a nursing home stay after a patient was released from a first hospital stay and is then readmitted to the hospital? Do they have to be stay another three days? Before I talk with the social worker/discharge people it would be helpful to have information from others who have gone through this before.

Thank you.
He has 100 days total per incident per year. So if he used 25 days previously he has 75 left. I would call the admissions person at the SNF rehab you want, they will tell you exactly what to do.
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