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Who are you caring for?
Which best describes their mobility?
How well are they maintaining their hygiene?
How are they managing their medications?
Does their living environment pose any safety concerns?
Fall risks, spoiled food, or other threats to wellbeing
Are they experiencing any memory loss?
Which best describes your loved one's social life?
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I. How We Work in Washington. Based on your preferences, we provide you with information about one or more of our contracted senior living providers ("Participating Communities") and provide your Senior Living Care Information to Participating Communities. The Participating Communities may contact you directly regarding their services. APFM does not endorse or recommend any provider. It is your sole responsibility to select the appropriate care for yourself or your loved one. We work with both you and the Participating Communities in your search. We do not permit our Advisors to have an ownership interest in Participating Communities.
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Mostly Independent
Your loved one may not require home care or assisted living services at this time. However, continue to monitor their condition for changes and consider occasional in-home care services for help as needed.
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igloo572's response implies that the resident does not need to show progress during the first 20 days of Medicare coverage. Please allow me to clarify. Assuming that the resident's stay in the SNF is only covered because the resident is participating in daily therapy and there is no "skilled" nursing care required, continued Medicare Part A coverage can only be legitimately offered if after the first week if the resident is showing progress OR the staff can justify why they think that the resident's response to the therapy program may change in a few days, due to an anticipated improvement to the resident's overall health or energy level, etc. It may be justifiable to allow someone who is not showing definite progress in therapy up to two weeks in order to try different approaches, changing time of treatment to align with observed energy levels, etc., but to go more than two weeks could be deemed fraudulent.
Medicare covers first 20/21 days. The following days up to day 100 will totally depend on their "progressing" sufficiently within their insurance guidelines.
If they got discharged from the hospital to a NH for rehab after a fall and breaking a hip. Which is número uno reason for advanced elderly entry into a NH. They need to get to & do their PT & /or OT and show consistent "progress". For family, they really need to do whatever to encourage and help their elder get into their rehab program and get positive progress reports. If the elder refuses to go to therapy (which they can do), or refuses to even try to do any of the exercises, or allow for measurements to be taken, they will be off the rehab benefit in short order. Really do whatever you can to get them to co-operate with rehab.
You are correct that the key to determining whether or not Medicare will pay is the IMPROVING condition of the patient (resident). As noted above, Medicare copays are determined by the specific Medicare plan the patient has opted into. "Traditional " Medicare has no copays for the first 20 days, but "Medicare Advantage" (HMOs) may have a copay from day one. The maximum allotment of Skilled Nursing care days for each "spell of illness" is 100 days, BUT in my 30 plus yrs in a SNF, the typical patient would "plateau" well before this time limit. If the patient is enrolled in a Medicare Advantage program, there will be a case manager assigned to track the patient's progress, usually on a weekly basis, to ensure that there is not a misuse of Medicare days beyond the time that it becomes evident that more therapy will not improve the patient's function. This decision is made by facility staff for traditional Medicare coverage, but this does not mean that the staff want to cut skilled services. (Medicare still reimburses the facility at a higher rate than almost any other payer, so it would hurt the facility to issue the "cut letter" one day sooner than justified by the resident's progress, BUT the facility also does not want to get into fraudulent practices by providing skilled services beyond what can be justified.) Medicare guidelines require that at least weekly progress be documented by the treating therapist(s). This becomes problematic when either the patient is not able to participate in therapy (uncontrolled pain, lack of motivation, unable to understand and follow instructions, etc.) or refuses to participate, which actually happens more frequently than you would think. The family (or resident) can appeal the decision by either the case manager or facility and this needs to be done IMMEDIATELY upon notification of services being cut. The case is then referred to "peer review" to see if the correct decision has been reached. Several years ago almost 100% of appeals ruled to reverse the decision but that is not the case now. It behooves the family to keep in contact with the therapy staff to get a better picture of the patient's progress, keeping in mind that HIPAA may prevent access to the info if the family member is not designated by the patient to receive this "protected health info". Please also keep in mind that the staff are not the enemy; 99% are truly dedicated to the patients they serve.
It's my understanding that Medicare will pay for 21 days as long as the patient is improving, and if the patient needs more rehab, then for the next 100 days Medicare will pay part and the patient's secondary insurance will pay the other part.
I hope other writers will jump in here in case that had changed.
By proceeding, I agree that I understand the following disclosures:
I. How We Work in Washington.
Based on your preferences, we provide you with information about one or more of our contracted senior living providers ("Participating Communities") and provide your Senior Living Care Information to Participating Communities. The Participating Communities may contact you directly regarding their services.
APFM does not endorse or recommend any provider. It is your sole responsibility to select the appropriate care for yourself or your loved one. We work with both you and the Participating Communities in your search. We do not permit our Advisors to have an ownership interest in Participating Communities.
II. How We Are Paid.
We do not charge you any fee – we are paid by the Participating Communities. Some Participating Communities pay us a percentage of the first month's standard rate for the rent and care services you select. We invoice these fees after the senior moves in.
III. When We Tour.
APFM tours certain Participating Communities in Washington (typically more in metropolitan areas than in rural areas.) During the 12 month period prior to December 31, 2017, we toured 86.2% of Participating Communities with capacity for 20 or more residents.
IV. No Obligation or Commitment.
You have no obligation to use or to continue to use our services. Because you pay no fee to us, you will never need to ask for a refund.
V. Complaints.
Please contact our Family Feedback Line at (866) 584-7340 or ConsumerFeedback@aplaceformom.com to report any complaint. Consumers have many avenues to address a dispute with any referral service company, including the right to file a complaint with the Attorney General's office at: Consumer Protection Division, 800 5th Avenue, Ste. 2000, Seattle, 98104 or 800-551-4636.
VI. No Waiver of Your Rights.
APFM does not (and may not) require or even ask consumers seeking senior housing or care services in Washington State to sign waivers of liability for losses of personal property or injury or to sign waivers of any rights established under law.
I agree that:
A.
I authorize A Place For Mom ("APFM") to collect certain personal and contact detail information, as well as relevant health care information about me or from me about the senior family member or relative I am assisting ("Senior Living Care Information").
B.
APFM may provide information to me electronically. My electronic signature on agreements and documents has the same effect as if I signed them in ink.
C.
APFM may send all communications to me electronically via e-mail or by access to an APFM web site.
D.
If I want a paper copy, I can print a copy of the Disclosures or download the Disclosures for my records.
E.
This E-Sign Acknowledgement and Authorization applies to these Disclosures and all future Disclosures related to APFM's services, unless I revoke my authorization. You may revoke this authorization in writing at any time (except where we have already disclosed information before receiving your revocation.) This authorization will expire after one year.
F.
You consent to APFM's reaching out to you using a phone system than can auto-dial numbers (we miss rotary phones, too!), but this consent is not required to use our service.
If they got discharged from the hospital to a NH for rehab after a fall and breaking a hip. Which is número uno reason for advanced elderly entry into a NH. They need to get to & do their PT & /or OT and show consistent "progress". For family, they really need to do whatever to encourage and help their elder get into their rehab program and get positive progress reports. If the elder refuses to go to therapy (which they can do), or refuses to even try to do any of the exercises, or allow for measurements to be taken, they will be off the rehab benefit in short order. Really do whatever you can to get them to co-operate with rehab.
The family (or resident) can appeal the decision by either the case manager or facility and this needs to be done IMMEDIATELY upon notification of services being cut. The case is then referred to "peer review" to see if the correct decision has been reached. Several years ago almost 100% of appeals ruled to reverse the decision but that is not the case now.
It behooves the family to keep in contact with the therapy staff to get a better picture of the patient's progress, keeping in mind that HIPAA may prevent access to the info if the family member is not designated by the patient to receive this "protected health info". Please also keep in mind that the staff are not the enemy; 99% are truly dedicated to the patients they serve.
I hope other writers will jump in here in case that had changed.