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My 85-year old MIL suffers from dementia, is unable to walk because her knees have deteriorated badly, has a blood clot in her lung and is bleeding internally. She is not a candidate for surgery because of a heart condition (anaesthesia would probably kill her.) She and my FIL live in the independent living section of a CCF. She was recently hospitalized with rapid heart rate, low BP (80/40) and delirium.
When she was released from the hospital, the nursing home did an evaluation and said that she is not in need of skilled nursing care.
How sick does someone have to be to qualify for skilled nursing care under the Medicare guidelines?
And what is their definition of "skilled nursing care?"
Thanks for any information you can share.

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You may want to find out if your mother was admitted formally in the hospital as "inpatient" or if she was on "observation status," meaning "outpatient." Many people get turned down for a post-hospital stay in a SNF because they didn't have a "qualifying" hospital stay. Here is a quote from the 2013 Medicare & You book regarding skilled nursing facility care:

"Medicare covers semi-private rooms, meals, skilled nursing and rehabilitative services, and other medically necessary services and supplies after a 3-day minimum medically-necessary inpatient hospital stay for a related illness or injury. An inpatient hospital stay begins the day you're formally admitted with a doctor's order and doesn't include the day you're discharged. To qualify for care in a skilled nursing facility, your doctor must certify that you need daily skilled care like intravenous injections or physical therapy."

What's happening for a lot of folks lately is that hospitals are keeping Medicare patients in on "observation" outpatient status and not formally admitting them as inpatient, which means Medicare will not cover a skilled nursing facility stay. It also means the patient often gets huge hospital bills for things Medicare won't cover during an "observation" stay, or stays in a nursing facility and later finds out Medicare didn't pay, so they have to. The Center for Medicare Advocacy has taken several legal actions against government agencies to end this practice.
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sympvt - so parents are in a CCF? Is this a IL to hospice CCF or just really a big retirement village with maybe an AL? Is it a CCRC - continuing care retirement community and what levels of care is really provided?

I think the type of CCF or CCRC will make a huge difference in how they will direct and evaluate her care. I sense you feel that mom's situation is going to happen again and then what to do, who to turn to...... You should go over the admissions contract with the CCF or CCRC. Did they do a big $$$ buy-in to be there and what happens if the facility cannot provide the level of care either of them need? Not both of them but either of them. All that should be in the contract.

My aunt was in a CCRC and it was some kinda expensive buy-in, she got ill within her first couple of months there and passed away. I was executrix of her estate and the contract she did with the CCRC was so one-sided in their favor as they controlled how the unit would be dealt with for sale, etc. My aunt was a widow so there was no well & healthy spouse left @ the CCRC but had there been, he would have had to stay @ the CCRC or if he moved they would be in default for their agreement. In may ways it was lucky she died because they would not and could not provide the level of care she would have needed. It was one of those happy retirement village types and their higher level of care unit was small and really just a way station for the resident to get moved to a true skilled nursing facility that was NOT a part of the CCRC. Look about to see what this place really can provide for the long term for your mom. If it can't, then look over the contract to see what can be done to get them moved and into a "tiered" facility with skilled nursing.
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People with Medicare are covered if they meet all of these conditions:
You have Part A and have days left in your benefit period.
You have a qualifying hospital stay. (3 days)
Your doctor has ordered that you need daily skilled care given by, or under the direct supervision of, skilled nursing or rehabilitation staff. If you're in the SNF for skilled rehabilitation services only, your care is considered daily care even if these therapy services are offered just 5 or 6 days a week, as long as you need and get the therapy services each day they're offered.
You get these skilled services in a SNF that's certified by Medicare.
You need these skilled services for a medical condition that was either:
•A hospital-related medical condition.
•A condition that started while you were getting care in the skilled nursing facility for a hospital-related medical condition.
Discharge planners are often led astray the patients who insist they are fine and that their family can take care of things, so they are released. If they can get to the bathroom, eat unaided and answer the questions, off they go.
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If your parents live in a CCRC, then there's a nursing facility there, right? Is that the nursing home that evaluated your mom? If so, and if you disagree with their assessment and think she needs 24/7 care, sit down with the director and discuss your concerns. I don't understand how Medicare comes into play in terms of the decision about whether she stays in IL or moves to SNF?
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In addition to Medicare requiring a transfer from an appropriate stay at a hospital before they will cover a stay at a skilled nursing facility for continuing medical care or PT rehabilitation, another critical requirement is that the patient must be evaluating as improving during their care, or having the ability to improve ur cooperate with instructions. The difficulty for patients with chronic conditions or dementia is that they don't qualify under the "improving" regulations. Skilled nursing care can continue to be paid for whereas anything else is considered long term care and it is NOT covered and NOT paid for by Medicare. Long term care can only be paid by long term care insurance already in place (previously obtained), private pay or Medicaid if the person qualifies.
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'igloo572' – CCRCs can be a good choice for someone relatively young and very healthy. If you move in at an advanced age and in marginal health (you have to pass a physical to get in), the numbers just don't make sense. And, for the family who inherits the apartment, there's the difficulty of disposing of the apartment. At a CCRC, you don't 'own' your unit in a traditional sense. The community is the only one who can sell it and in the meantime, heirs will have to keep up a monthly maintenance payment - not as high as the rent, but substantial. My friend had to pay more than $500 per month for over a year before her mother's unit was re-sold.

And, "sympavt'. If your in-laws are in a true CCRC, then your MIL should be able to move to the community's SNF (or AL, depending upon her needs). Again, I don't understand why the concern about Medicare guidelines. This is a question for the staff and director of the CCRC. Review the contract, then meet with them.
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Isn't - yeah totally agree with you on being young & healthy for a CCRC. For my aunt, she had an aneurism so it was quick and over. Took over a year to sell as the CCRC has to vett and approve the buyer (this is extremely subjective and I bet filled with discriminatory practices). I was able as executrix to negotiate the maintenance as there was money in the estate, her contract allowed for overnight stays/short -term visitors which the attorney told them we planned on using to the maximum allowed if they expected full maintenance and we planned on stringing out probate to the full 4 years to deflect with family in-fighting and there was lots of other issues with other property that had to be dealt with that would take time. But most folks don't have this luxury and the CCRC has the upper hand.

As you said, review the contract then meet with them.
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Thanks to all for some very good information. My MIL is now in her IL apartment where she lives with FIL. She has round-the-clock private aides from an agency (wonderful people, no complaints but not covered by Medicare); she's also in hospice care, which means palliative care only. The hospice people supervise the aides and provide support to the family. MIL is resting comfortably, but we all know she is fading away.

I'm sorry if I confused the issue by asking about Medicare. My basic question was that I wanted to know how sick somebody has to be for the medical community to consider them in need of skilled nursing care.

It seems clearer to me now. It would help me also if any of you out there have a loved one who was released from hospital to nursing home, can you give me details, for example, what their diagnosis was, and why they required "skilled nursing care."

Thanks in advance! I appreciate your help.
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