When your LOs went to a nursing home, how many outside specialists did they keep?

Hang on. Someone should be able to answer your question.

Dear Treeartist, I'll be watching this thread with you. My mother, who recently moved to assisted living, has 8 health care providers: PCP, dermatologist, neurologist, cardiologist, ophthalmologist, dentist, audiologist. The ALF doesn't provide reliable transportation and no real mobility assistance to passengers. I'm trying to figure this out, too.

Oops. That's only seven. There's also an orthopedist but only when she falls --- which she has done several times.

Zero, but then my mom's been palliative for years.

My father is in a Personal Care Facility (like Assisted Living) and due to his Medicare supplement it is more cost efficient to transport him to his own Doctors. If he were to see the facility's physician the supplement he would be responsible for 40% after Medicare paid their portion. I think at times it would be worth it to see their physicians as it is becoming more difficult to transport him.

When my husband was admitted to the skilled nursing facility, he had been on home hospice care for a while. Hospice continued to see him at the facility, but he did not live long enough for me to consider contacting his other specialists. When he fell and broke his hip in the facility, I was given a choice of their sending him to a hospital for surgery to repair it or "letting it heal" while he was in bed in the nursing facility. I told them not to send him to the hospital because, due to his poor heart and lung function, I was sure he would not survive the anesthesia. I didn't want to live with the thought that my choice might have killled him.

My dad sees the NH physician as his internist. The only specialist he had was a retinologist who was watchful waiting on his very early macular degeneration. I’m not going to have the wheelchair van transport him there for more agonizing testing that goes on for hours. He needs new dentures since he’s lost so much weight. He and I went to a dentist 5 visit’s for new ones and then he refused to wear them so he could get used to them. Called the doctor a quack and now wants to go to a different dentist. I don’t think I can go through that again. The first pair was $3300 down the drain. He also acted out and was embarrassing as this dentist was someone I had worked for in the past. The other day I asked the DoN to have the doctor check his ears to see if they need to have wax removed and she said he might be referred to an ENT!!! WTH? I said NO! You all can do that there, I’m not sending him to an ENT. Lazy assses!! Sorry for my language but that just made me so mad.

I will also be watching this thread. My mother is still living at home, but one of my concerns about possible nursing home placement is how we will deal with the 7 or 8 specialists she's seeing now. These multiple appointments have become a major time and energy sink for my sister and me, and I would hope that if Mom goes into care, we would be relieved of at least some of these.

My folks went into AL a little over 2 months ago, both late 80s, both with increasing dementia, mom with multiple health and mobility issues.

All the doc appointments had been a huge hassle, Dads scary driving, having to sit for hours in waiting rooms only to be told YOURE GOOD, SEE YOU NEXT MONTH.....And this usually by an assistant.

When they went into care I immediately signed them up for the in house doc service. The place has a doc, nurse practitioner, LPNs, RNs and can take care of all their needs. Does mom really have to get loaded up and driven to her cardiologist, her urologist etc? No...Staff can assess her meds and adjust if needed.

It has been a huge burden lifted for me and my folks.

This is interesting to me. Our family found that the specialists my mom saw, the same ones whose offices called regularly to remind and set appointments, dropped her like a rock when she entered a nursing home. We mostly used the in house doctor, which was normally fine, but there were a few times she had to see a specialist. We did all the difficult transportation and the specialty docs she’d loved before were competent to her, but only minimally kind, sort of like she wasn’t a person anymore. It’s amazing and sad how quickly a person can disappear from the outside world once they are a nursing home resident. But thankfully, for the most part, the doctor at the nursing home was good and kind. If I were you, I’d be asking what all the facility doc is comfortable handling and which things they’d prefer you have handled outside

I do wonder why an oncologist would be needed 10 years after cancer. My mother had cancer of the breast and colon. Once she was in remission 5 years, no one suggested further visits. It's been over 20 years now. If the nursing home has good in house medical care, I would go in that direction. It will mean a better information flow between providers and daily caregivers. If there are specialists that she sees for eye or dental care perhaps keep those but try to find out if you can minimize the number of appointments. I wish there were an in house doctor or visiting doctor at my mother's AL. One wonderful benefit to me is the transport service provided twice weekly since my mother is mostly in a wheelchair. Getting her to doctor appointments was a horror show for me and led to permanent injuries (mine) from awkward transfers from her big old house to outside and then to my car. Also getting that heavy wheelchair in and out of the trunk. My advice is take whatever services are provided by your mother's nursing home.

The answer may depend n the type of Medicare and supplemental plan you have and whether the in house doc is an employee of the facility, in a private practice that takes your LO's insurance or is in an HMO that requires being a member. My parents have such amazing supplemental insurance with all free meds that they want to keep all their independent doctors. At 92, they still take the IL transport to appointments; however, we are moving them closer to us this month so we can help them with that. We are going to use the internists that come to the facility as part of their practice as well as the podiatrist that does the same, but we will have t keep going outside for urology, vision, dental, dermatology, etc. So, it is important to take a lot of things into consideration. I would be wary of a facility that pushes a particular doctor or Medicare plan....

Oh, and Harpcat, my doctor old me that my insurance would not cover her removing my earwax but would cover it being done by a specialist... seems dumb to me, but it is something to be aware of when making decisions. Insurance is just too complicated.

Treeartist, I would make sure that you know what is going on with her care if you choose this route, I was running my dad to Drs appts, labs, etc. and frankly I was worn out with it all, then the manager of the AL said, you know we have Drs that can come and take care of him, oh what a great idea. Then the 1st time the Drs office saw him they sent a Nurse Practitioner that wanted to change all of his meds. I went through the roof he had just spent 60 days in hospital and skilled nursing facility to get stabilised and back on his feet, you see him for 5 minutes and want to change everything? No freaking way. They also had to have the breaks put on coming in to see him just because they were at the facility, come in say hi and insurance gets a 180.00 bill, not on my watch. I still have him signed up with them but I keep an eye on his insurance and I require they send me visit notes to verify if he was seen or got a hi then bill. He still has to be taken to specialists, so it helps with majority of his appts but not all.

First of all - What does LO stand for?

My husband has several doctors also and it seemed like he was always going to one or another. Once he was in Hospice they are meeting the needs of the issue that is going to end up being the end. So he didn't really need to see the other doctors for now. But your loved ones are in assisted living maybe that different.

Corinna, LO stands for "loved one".

I finally figured out that doctors keep patients coming back whether they really need to or not. I believe it's for the almighty dollar and to prevent liability issues. I also think they order tests well beyond the time they're of any use. I drove a 92-year old woman to her oncologist's office and as she left, they scheduled her for her "annual mammogram" for a year's time out. Why is a 92-year old woman getting a mammogram? Ridiculous waste of money. That's well beyond the age any medical body recommends getting mammograms.

I saw it with my mom. She had ongoing heart issues that were stable. But her doctor made me bring her back every year to test her, even though her a-fib wasn't going to get any better, only worse and we all knew that. But I had to take her in order to get her prescriptions refilled after a year, even though she was stable and not showing any issues. When she was 96, he wanted to do an echocardiogram and then a chest x-ray. She was beyond ready to go but after arguing with him twice about it, I caved. Totally useless in my opinion. But I was strong-armed by the medical system to do it.

I think it's a blessing to seniors in nursing homes if they just see one doctor except for maybe eye care. When you get to a nursing home, the reality is you're not getting any better. Your care should be geared towards comfort, not cure.

My experience with rehab and nursing home doctors is not good so a lot will depend on what is available in your area

Even though she is immobile I still take mom out to her own internist of 25 years but it is difficult for her memory care facility to get orders sometimes especially if she falls ill on a weekend . I also take her out to her own dentist since oral care is non existent in facilities

When sepsis landed her in the hospital and then in a nursing home for a brief one month stay, we were stuck with the house Doctor whom I never saw and the nurses had trouble getting hold of to even remove an iv in order to get her back to her memory care facility

The other downside is paying for transport now that I can't put her in my car - $25 for the facility van but it was $140 to get her from the hospital back to her facility after the flu over the holidays

My mom has both Medicare and Medicaid. We kept her specialist the neurologist and use the internal doctor at the facility. However, if I'm not satisfied with the
Treatment given by the facility doctor I will and I can take her to someone else and pay the out of pocket cost ($60). You should be able to keep her specialist. Good luck!

There’s no one good answer, depends on health, transport issues and so on. But for a long distance caregiver like me this AL has been heaven. Not only do I not have to worry about dragging the folks all over town to see docs they really don’t need to see, but the AL staff set up the podiatrist to visit my folks and they’ve both been to the hair salon.

This is great stuff for us.    My mom’s toenails and hair were getting to be scary movie grade.

Generally, the facility provides the primary care physician. Specialists are often necessary out of facility depending on the patient's needs. My dad continued to see a cardiologist (pacemaker/defibrillator, neurologist (seizure disorder), and urologist for most of the time he resided in a nursing home. My mom currently is in nursing home and she has maintained her cardiac specialist (pacemaker). Your loved ones existing conditions and his or her ability to travel to a doctor's office will determine their choices concerning outside care.

I wouldn't drop your doctor's. The doctors affiliated with nursing homes are General Practitioners. I would definately keep the phychiatrst. Also, the eye doctor since he has been treating them. Her cancer doctor I would ask if one year visit would be OK. I may ask if you take Mom for her yearly Mamogram could he just review the xrays and only have Mom come in if there is a problem.

The NH's doctor was Moms primary stand in at the Hospital so I went with him because he had seen Mom. I allowed their eye doctor and dentist to see Mom but Mom had no problems in this area. I did drop her Thyroid doctor because the NH doctor agreed to run Moms blood work every few months and contact her Thyroid doctor with any problems. Her stomach Dr I dropped because he was called in after a hospital stay. I had got him down to a year visit before that. She was not having any problems.

My mother kept zero specialists when she went into the NH. She was at the NH for the rationale, if you will, that she needed the services of a nursing home. She no longer had the wherewithal to seek the specialist.

Another question about this: what if the patient is on Medicaid? Are specialist visits/treatment covered? Are the copayments the same as before Medicaid was paying? If so, how can the patient pay the copays out of the tiny monthly allowance they're allowed?

I believe that the coverage for doctor's visits remains the same. When a NH resident is covered by Medicaid, they still retain their Medicare benefits. If they had Medicare supplemental insurance, they can continue to have that also. So, short answer is that they can continue to see their specialists. Medicaid will provide van transportation to the appointment. The only thing to change that is a more practical matter. If they are no longer capable of going to an office visit, they may not continue to see their cardiologist, for example.

I think it's a good idea to keep an outside PCP. One problem with the in-house Doctor (more often a PA) is that you may not be aware when she is seen, what was recommended, or how what was said affects the patient. The inside PA or Doctor is handy for small matters, but when too much power is put in the hands of people who are paid caregivers is not a good thing. We had a bad experience where the PA didn't take appts but just saw whoever was in line - leading to several "visits" a week by my friend who has memory loss - and each "visit" being billed as an office visit to Medicare. In addition, the PA diagnosed my friend as having Dementia which (while true) scared her without any family or friend knowing what had occurred. The objective was getting her medicated (for which there are add-on charges). Not saying this is normal, but that it happened because we thought it was a big "convenience" for her to see the PA rather than be transported (for which they also charge Medicare) for outside Medical appts. Just be aware that it is NECESSARY to stay involved.

Thank you to everyone who answered and kept up this thread. Yes, my parents are able to keep their Tri-care. I believe what I have gotten from your answers is to, of course, keep the specialists that cannot be duplicated at the NH, but find out what exactly the NH is capable of doing. I think they had so many appointments prior to going into the NH because, not only did they have excellent insurance, but we were hesitant to go against the doctors’ recommendations. I remember having a conversation with my brother over this issue of multiple wellness visits, and he said “ I don’t want to make that call, and then it be on my head”, so the numerous visits continued.
I think we are going to feel more comfortable with letting the facility determine the necessity of all those requested specialist visits. I agree with the need to keep her psychiatrist. The doctor or nurse practitioner there is not qualified to treat my mother’s bipolar disorder. Any one of you aquatinted with this know proper treatment means the difference between functioning normally and utter hell. I was surprised to learn that it may not be necessary to see her oncologist after so many years of being in remission. I will look into this.
I do want to address one of the misconceptions someone posted about that residents in a NH don’t need curative medicine. It is true that a NH is the end of the line residence. My parents were never in an Assisted Living facility because, we, their children, Assisted them to live in their home for over 15 years. When it became too hard for us to do this, their ADL’s (adult daily living skills?) were so poor that they wouldn’t qualify for AL and had to go to the NH. Nevertheless, the residents in a Nursing Home need more professional care, both medically and physically, but many will live for many years in this end stage residence. Yes, there are those there who never leave their beds, but the cafeteria is also full of residents who can feed themselves, and then make their way back to their room or to some activity. I’m sure there are Hospice patients there, but the majority are not, and those residents will continue to get curative or preventive medical attention the same as anyone else outside the facility.
Again, thank you to everyone who answered. I am going to share your answers with my siblings. Your help is so appreciated and such a blessing. God bless all of you.

I think you have to decide who and what is most important. I think a general practitioner away from the nursing home would be my first choice. Someone who's not connected to the facility, that I would keep. I know my mom would want to continue with her primary care physician. She also really likes her cardiologist. But for all the other needs I would go with the nursing home's offerings. Decide what is still important. An oncologist after ten years after a cancer diagnosis and treatment (as someone else has mentioned) is probably not needed. My grandmother still insisted on a pap and mammogram at 95 years old. I tried to talk her out of it but she insisted. If you can pare it down to the one or two that mean the most to your family that would be what I would recommend and what we did for my mom.

(Sorry this is so long, but this is so close to my heart...) Hi Treeartist - DON'T DO IT! My Mom just died November 13, 2017, so it isn't an issue any more, but for 2 1/2 years, since she went into the "system" from a broken hip/wrist (which was surgically corrected, even though the surgeon offered the "alternative" of just leaving her in bed but I opted to take the chance, because my independent and strong Mom would hate me forever if she didn't have a shot at recovery). She flew through surgery and was out of the hospital in four days. I took her to every doctor's appointment, outside therapy care, etc. (once we were able to transfer/transport her in my car) or followed ambulances, medivans, etc. You need to keep her Specialists (and personally, I kept her Primary). The nursing home will not follow her issues the way you - or the specialists - will. A "general doctor" coming in once a week at a time she doesn't necessarily need him, and with a lot of other people potentially needing to see him, just doesn't cut it. PA’s can also be overloaded, and as far as nurses? Are there really that many qualified nurses, or are most of the caregivers CNA’s?

I too wondered sometimes whether it was worth it? It took over my life sometimes (most often?) but there were medical situations that the nursing home would not have recognized – or, frankly, cared about – that I noticed and addressed. The emphasis in a nursing home is general geriatric care, and I think that emphasis is different than someone who truly, individually cares. I’ve been told by more than one doc that Mom would have died several times – and much earlier – if I hadn’t “advocated” for her, and to me that meant taking her to appointments, visiting nearly every day, and really knowing what was going on. You just won’t get anywhere near that level of care or control, with nursing home staff. If you have POA, ask what meds they have her on, etc. They will know you are involved, vigilant, and usually pay more attention.

I couldn’t even get them to stop giving her laxatives without her knowledge if her system didn’t exactly follow the “bowel protocol”. She would be totally embarrassed and distraught when without warning she got explosive diarrhea at the dining room, or even in her room. (She was totally continent, but that didn’t always mean, either, that they were quick enough to respond to the call button, but this was a different issue!) Every time this happened, I went to the meds nurse and asked whether they’d given her a laxative, and every time they had, I repeatedly told them to let her know, to warn her, to start off with a smaller dose, etc., try prune juice! Before she ended up in the nursing home, she’d had issues with chronic diarrhea which after extensive testing was finally identified as a reaction to the anti-acid she was on (Prilosec). This is not uncommon! I know now that I should have demanded this instruction be placed on her MARS (record of what they were supposed to follow in her care), because then they had to pay attention.

She had hearing problems, which just seemed to get worse and worse. I looked in her ears and could clearly see they were plugged by a large amount of wax… I told the nursing staff, and nothing was done… Eventually, I carefully pulled it out with blunt tweezers… She had a very painful corn on top of her left little toe, and that went untreated because most of them (young) didn’t even know what a corn was, or how exquisitely painful it could be. I took her to a podiatrist…

This was all in a generally respected and “good” nursing facility. They just have too many people to take care of, and care staff (CNA’s) change frequently and just aren’t educated (and in some cases, caring) enough to pay attention. I was probably listed in her records as a capital “B”, but that’s too bad. (They didn’t like it either when sometimes I “advocated” for other residents who didn’t have anyone at all coming in to visit or check on them.) “Minor things” - A roommate of hers never wore her dentures except for meals because they were so ill-fitting. Even with Medicaid, there is a level of care expected and covered… Another resident (a very large woman who was in a wheelchair and I became friends with, complained that her fanny hurt. I bugged staff until they finally rolled her over enough to see the bedsore that went all the way to the bone.. She spent 2 weeks in the hospital from that.)

Eye care? Cancer followup? Bi-polar? Really? Not even close with a general nursing home doc… Just with the Bi-polar disorder, my guess is that she would end up generally sedated because she was “acting out”. I know – I REALLY know – how hard it can be and how much of your time it can take to personally provide the individual care and attention. I’m by myself with no siblings or kids, so it was “only me”. Don’t be afraid, either, to follow your own instincts because you know your parents far more than any facility staff will. I will be forever grateful I was there and able to give Mom that care, and I always knew that unfortunately it wouldn’t be forever… (BTW, I was taking Mom to outside physical therapy and occupational therapy every week… I’m not even sure who I finally bugged enough to get that approved! She was doing really well – amazed everyone – and could even get up from a wheelchair and walk a pretty good distance with a wheeled walker. It was also a chance to get some quality time in away from a facility setting, and to stop afterwards to have lunch or a treat.)

November 13, a CNA was giving her a shower and transferring her from the wheelchair to the shower chair. Mom slipped on the floor – told the CNA her foot was slipping, but the girl couldn’t stop her fall. Mom broke her tibia and fibula in her lower left leg. No one realized she’d actually sustained that break for a good part of the day; she was painful but it was thought to be a sprain. Toward evening it got much more painful, was swelling, and badly bruised. She was taken by ambulance to ER, where her injury was diagnosed. They put a splint on her leg and sent her back to the nursing facility. The nursing staff just couldn’t take proper care of someone this badly hurt. They couldn’t (weren’t allowed) to give her the levels of pain meds required, and over the next several days she declined until she wouldn’t eat, wouldn’t move, and in fact didn’t even recognize me. She just moaned and said she hurt… The fifth day she starting screaming and finally went back to ER. She was admitted to the hospital – still screaming – and for two more days she was in horrible pain. The hospital wouldn’t administer the levels of pain control (opiates!) she needed, because they were afraid it would kill her… Seriously?! Her kidneys were damaged, they thought she’d had a mild heart attack and probably had a clot in her lungs – her electrolytes were totally screwed up. I was totally distraught, and finally the staff hospitalist doctor talked to me and asked me what my goals were? I said I wanted her out of pain, comfortable, and if that took her, so be it… I told him if there was any potential for a life with meaning and quality at that point I would fight with teeth, claws, and my last breath for her, but this was just a fight “we” couldn’t win this time. He agreed with me 100% and she went on hospice (staying in the hospital, although they asked whether I wanted her to go back to the facility). All “support” was removed, and it took three days for her to pass. I am still raw and “up and down” with my emotions, but I can at least console myself with the knowledge that I did everything I could for her, and the fight had to end at some point. Her life had value and as much quality as I could ensure, and that helps cushion her loss…

I’m sorry this “answer” got so long! Your question just resonated with me so much, and brought back so many memories, and most people here probably won’t get beyond the first paragraph or so… Mom was 97 years old, and would have been 98 in two months, February 8 of this month…

Image, thank you for your response. I read the whole thing and will probably reread it. Do not fear, even though we may leave the general medical to the nursing home we are very aware of how much we still need to advocate even for treatment of colds, etc. My parents have daily visits. I guess my original question was in response to the facility asking us to give over more of the care to them. At our next care meeting (soon), we will address this issue to make clear which specialists we will not let go of.
I am sorry for your loss, and I thank you for taking the time during your recent bereavement to offer help. Rest assured that I will take your words to heart. At 97, your mother was in much better shape than my mother ten years younger. We children are happy and available to meet the transport and be with my parents during the visits, but we have to take into account how exhausting and disruptive they are for my mother. My father is stronger, and like your mother, sees it like an outing.
My prayers are with you at the end of the journey with your mother.