NH questions and some do’s/dont’s. New to this, can you share your experiences?

My brother in law is in a nursing home and they handle making all his appointments and transporting him there. Some nursing homes want to use their own outside specialists so you should check on that, as your aunt might not be able to keep her existing specialists. If she already had appointments set up with certain doctors before entering the NH, perhaps that's why they thought the family would transport, since the NH did not set up those appointments. Generally nursing home residents have the NH affiliated doctor as their PCP, and that is who would make referrals for specialists. One of my husband's brothers is the medical POA for a brother who is in the nursing home. The NH will sometimes check with him and my husband, who has financial POA, if a referral is needed to a new specialist, in case the family has a preferred one or the NH brother had been seen by someone already.

Here's what happened in our case. Once it was decided that LO would need to remain in a NH, we didn't know what to do either. My LO always considered doctor's appts as a type of social call and repeatedly asked about seeing her "regular doctor" as well as the "sugar doctor", "foot doctor" and "heart doctor." She really didn't care what any of them said and never wanted to do what they told her (unless it was popping pills and trying new/better pills), but she kept asking. I called her "regular doctor" and THEY discontinued her as a patient when I told them she was in a facility. They told me that my LO would be seen at the nursing home by the staff physician and that was the protocol. OK - that one was simple.

When it came to specialists, it got a little dicey. (Disclaimer: my LO is a full code, including compressions. This is due to family dynamics/politics. The protocol for a DNR might differ, but hopefully my answer will still be helpful).

We broke ties with the "sugar doctor" because LO was still sneaking food and being noncompliant with diabetes restrictions. We determined that there was nothing a specialist was really helping with that the in house doc could not manage.

The "foot doctor" is not in the equation either because foot needs are handled within the facility. Same with the eye doctor. Same with the dentist. Same with orthopedics. She does not see any of those anymore as they are redundant with what the NH already has (and we are satisfied with their assessments).

She does still see the "heart doctor" from time to time, We schedule these and attend the appointment with her. NH provides transport. We provide NH with the outcome of the appt and any changes needed. We do the same thing with neuro. We schedule, NH transports, we are present at appointment and we give the results to the NH following the appt. We are able and willing to be there for these appts. If you are not able and willing to be at these appts, then you need to make sure NH knows this. They may be assuming that it's YOU who wants these doctors involved and therefore they are wanting you to make it all happen. If you can't be involved to that level (some can't and it's OK) then you need to make sure NH is clear on this. Maybe a care conference needs to be scheduled so all parties can discuss the necessity of these appts and HOW they are going to get scheduled and carried out.

It's different if NH is the one who wants her to see an outside person. For example, NH thought she had a contagious skin condition and THEY insisted she see dermatology ASAP. In that case, NH scheduled, NH transported, NH accompanied to the appt and NH relayed the pertinent details to the powers that be in terms of med changes or whatever.

In general, NH will try to get the family to do as much as possible. To a degree, I don't blame them because they can't be worrying about a multitude of appointments for dozens of elders when many of the appts are not truly needed. I think it's a matter of getting down to the nitty gritty as far as which doctors need to be involved and then discussing how to address that. It may end up being not many outside appointments at all and you may find that you can assist with them more than you originally thought.

For both my mom & MIL - both on LTC Medicaid - when they each entered a facility, the MD / medical director of the NH then became their primary physician and it was him &/or the DON (director of nursing) for the NH that basically determined if they needed to be seen by outside provider or stay at the NH. (Imo the DON is the power center and goddess of the NH and if u need to get something done, she’s the go-to.) The NH administrative side can be put into their lane by the DON….. so keep this in mind. NH needs to now be dealing with Aunties coordination of care within providers affiliated with this NH to have the optimum use of staff and time. Make that your mantra.

Please realize that if they have now applied for LTC Medicaid that their prior health insurance will stop & they now change to being a “dual”, so on MediCARE and Medicaid. & it will not necessarily be cleanly done if she was on blue Cross, Humana, etc. As a matter of fact could be a real butt rash, more on that below. For MIL she had done a Medicaid Advantage Plan and of course those have zero provider network for Nh, so there needed to be no old doctor visits as they would be out of network and she had no $ to ever pay as she had filed for LTC Medicaid. For my MiL, like yours, she viewed these as social and wanted every MD visit to be a full outing. Hubs had to put the hammer down on her calling her old docs and scheduling. The NH had all the residents seen by the medical director at least twice a month and then put on a schedule for podiatrist, cardiac care (speciality RN), diabetes (again so RN) and for anything that seemed seriously amiss they went on an medical transport run to the 2 ERs that had a relationship with the NH. All billing to Medicare or Medicaid.

For my mom she was on a beyond good FEHIB BlueCross and had zero copay and almost every clinic, provider took FEHIB. Couple of months before moving from IL to NH she had retinal speciality MD eye surgery. It had a 3 mo follow up. She was still on meds and had the final post-op visit after moving to the Nh. The medical director of the NH also has his own gerontology practice, which took “duals”, so the retina office coordinated with gerontologist office to get meds and interocular checkups done by the DON. I took her to the final post op visit to see retina guy & he only billed MediCARE and had already been paid by BCBS for all surgery stuff. The DON knew of the visit as did the medical director, it was a perfunctory post op visit; mom was ambulatory so not an issue. But other than that, all medical now done at or ordered by the NH till she went couple years later onto hospice and the hospice MD works with DON/MD as to care plan.

Now where it can get real in the weeds once they move into a NH is that until they are eligible and approved and on LTC Medicaid, their old health insurance is still in effect. So if they are on BlueCross, it technically still is their secondary payor. But once LTC Medicaid happens, LTC Medicaid & Medicaid as health insurance will go back to the date of the filing of the application for paying for services. This could be 3 -4 maybe 6 months. Then what will happen is that once the old health insurance finds out, they will do a clawback on any payments made during that period. If your Aunties NH has any providers who bill independently (likely to be PT physical therapist or ST speech therapist if it does happen) and who do not accept Medicaid, they will have their payments clawed back and will be very not happy. To make all this more convoluted, the clawback may not happen for months or may be months till the provider realizes it and then bills the elder who is now on Medicaid and has zero $. Again very not happy. Why a Nh would have outside vendors who do not take Medicaid is beyond me, but it does happen. If this could be an issue for your Aunt, ask!

No No No. Once one is in the nursing home, all of his/her needs are met by the NH. There is a Dr. on staff, there is no need to take her out of the facility. once my father went to the NH, all of his appointments with outside Dr's were cancelled. The nursing home takes care of all of the medical needs.

So thank you all for your input. We assumed that she would be under the care of the NH staff until we got this
call. Of course she may be telling them at the NH that we were taking her to these appointments but who knows. We have the DON calling us tomorrow to go over most of this so hopefully she will be able to help. Guess she had or has an eye appointment that she was going to miss and started this ball rolling