Does rehab discharge too quickly?

Hi Sundial! I used to work as an Occupational Therapy Assistant both in nursing homes and in home health but am taking care of my own mother with dementia now. However, I will try as best as I can to answer your question. First of all, it is somewhat true that therapy is racing against the clock in some circumstances depending on the insurance provider, whether it be Medicare, Medicaid, or private insurance. Medicare does pay 100% of the first 21 days of skilled nursing and rehab care. Then after that it goes to 80% coverage up to 100 days. However, therapy can only continue if it is 1. Deemed medically necessary, and 2. Progress is being made towards the stated goals. Therefore, in certain instances when there is no supplemental insurance in place, it can be a race against the clock if the patient cannot afford to continue with the therapy. Secondly, once the patient starts to plateau and is no longer expected to make any further progress in therapy, the therapists must discharge the patient from therapy or risk possible denials from Medicare or other insurance. In the case of a stroke, due to the many different factors concerned including the severity of the stroke, the amount of damage to the brain, the amount of spontaneous recovery including sensory and motor return, patient comprehension and motivational factors, family support and follow through, and discharge plans, there can be a wide range in the outcomes. For instance, a patient with good return who is highly motivated and able to follow through with recommendations including safe transfers, ADL retraining using compensatory strategies, and therapeutic exercises will generally have a much better prognosis than someone who, say, has total paralysis of the affected side, is severely aphasic and cannot comprehend or follow through with instructions or communicate, and refuses to or is otherwise unmotivated to participate in therapy. Also, in cases of a stroke there are some people that respond very well to "advanced technology" such as electrical stimulation and others who don't show any signs of improvement at all. Some people can go through months of therapy and make very rapid progress and others hardly make any progress at all. Of course, whether the person is planning on returning home or staying at the nursing home for long-term care makes a difference in the goal-setting as well. There are also other factors to consider such as the patient's cognition, overall medical condition which may contribute to his or her own morbidity issues, etc. So based on all those factors a therapist must determine, usually weekly, whether a patient is expected to make further progress or whether it is time to discharge the patient from therapy before facing possible insurance denials. Back in the late 1980's when I first started working in the field we could almost work with someone indefinitely. However, now with the new Medicare guidelines which are changing all of the time the push is to get the patient to his or her prior level or at least his or her prior level of functioning as quickly as possible so that the nursing home doesn't face possible denials and end up in the red. Obviously, there is also a wide variety in therapists across the spectrum as well, and probably some that prefer to discharge patients earlier than others. I have found this to be true even in the case my mother's care as well as with the many therapists I have worked with over the years. Some therapists are quicker to discharge patients, and then others prefer to hang on to someone as long as they can possibly "tweaking" the short and long-term goals as necessary. Some use more technologically advanced equipment and focus on getting as much return back as possible before discharge from rehab, and others focus more specifically on getting patients more independent in ADL's such as bathing, dressing, toileting, and transfers so they can return home safely. So you see, depending on your father's situation perhaps the therapists did discharge too early, but perhaps he had already plateaued and they didn't feel as if he was going to make any further progress in his case. In my experience, once the rehab therapists get the patient to the point where he or she can safely return home, often the home health therapists can take over from there. However, you are right in saying that home health usually only comes out a couple times a week for a short period of time, and the emphasis now is more and more on training the patient or the caregivers on home safety and then on what exercises to do to continue to make progress. Long gone are the days when we can stay and work with someone indefinitely now that there are new timelines in place with the insurance companies as far as how long we can be expected to work with someone for any given medical condition. It can be very frustrating, I know, especially for family members who feel that their loved one is being discharged from therapy too early just when he or she seems to be making progress. Believe me, it can be frustrating at times for the therapists as well, but the push in home health now is to educate the patient and family on what to do for their own progression and care and not to provide that care on a long-term, continuing basis. Also, once that patient is no longer considered "home-bound" and can possibly continue therapy in an outpatient setting where they can receive more "technologically advanced care", then that is what is expected and as far as what the insurance companies will deem "medically necessary." However, I will say that I saw one patient for home health for many months 12+ years post-stroke! Because she was so determined to get better, to follow through with her exercises, and live independently with a little home health care, we were able to continue working on her arm and hand exercises with certain "functional goals" in mind so that she was able to gain 90% of her functional use of her arm and hand back to the point where she basically didn't need home health care anymore. But let me say she was an exception to the rule rather than the norm, because not all stroke patients can be expected to improve like that because it depends largely on the amount of "sparing" in the brain whether people will get any motor return back at all, but it is possible. You can retrain the brain and develop new neural pathways to some extent, but it also depends on how motivated, determined, willing, and cognitively able that person is to work at it, and of course most are not and therefore tend to fizzle out before they begin to show those type of remarkable results and were willing to work hard at it. In fact, I used to joke with my husband that 80% of the people that I worked with really didn't want therapy, but there were always the 20% that did. To be honest, those are the ones that therapists may tend to hang on to a little longer because they generally tend to make better progress.

Anyway, I hope that helps.

My dad who was 88 at the time of his heart attack was discharged after 1 week in the hospital because he was "too" well and was doing running circles in the halls. Thinking that this was wonderful because I had never experienced any healthy issues with him before this. Hospitals have criteria when to release a patient. In his case the PT and OT thought he was good enough to go home with a twice a week nurse coming to the house to check. He was also sent to a cardiac rehab for 6 to 8 weeks 3 times a week. My mom who has dementia was the only one that could was home and I knew that was not going to work since she didn't cook or drive anymore. I moved in thinking it would be for a few weeks at the most and it ended up being for 6 mos. and I had to put my mom in a facility. Fast forward a year and he had to have a stent put in. Again, he did so well he tricked the dr. into releasing him to me. I questioned him going into rehab facility and dr. said he just didn't think he needed it. Well, I brought home for a few days I thought where he quickly went downhill and ended up passing out. Everything was ok and we got him into bed but boy the next morning I called the dr. and got him into a rehab facility where he could be watched and taken care of by people who knew what to do. Point of the story is this: #1.....Like Rabbit72, my dad showed them what he wanted to show them because he wanted to go home and not into a facility. Lessons have been learned from that unfortunately. #2.....And like Katie222 I also made him get up and to do the exercises on days that he didn't have them at the rehab or nurses came. That way he did get stronger but he also had help and guidance doing them. Hope this helped. And by the way, I still have him do some exercises and walking at 92 1/2 years. He lives on his own in a retirement facility. Good Luck and God Bless

Thank you so very much for that detailed explanation, Imccarthy1. It explains so much about why we do tend to think that people have been discharged too early, and why it is, unfortunately, necessary.

I knew it would come back to bite us when insurance companies began telling us what we could have done and when instead of the doctors. We are truly at their mercy these days.

Any kind of rehab, whether PT or substance abuse, requires a STRONG motivation on the part of the patient. My insurance covered inpatient rehab ten days after a knee replacement. Then there was out patient PT three days a week. If you don't do the homework the other 4 days, you regress.
My roommate at rehab was there for much much longer, they finally gave up and sent her home. She laid in bed unless they carted her off to PT. I'm sure once she got home she became a couch potato.
My cousin, age 60, was so over weight, the surgeon refused to replace both knees. She lost 80 lbs (36kg), got the surgery, did ten days in rehab and went home. She was MOTIVATED.

The rehab facilities have only a certain number of days to work with the patient while insurances pay for the facility, after those certain number of days, then the patient has to pay the bulk out of his own pocket if they wish to remain in the facility. Plus patients tend to be happier when back at home.

My Dad did pretty good in rehab after having heart attack, but once home he ignored all the exercises... he would act interested when the therapist came to his house... but after he/she left, Dad was back to ignoring. There isn't much a therapist can do if the patient isn't willing to help themselves, thus insurances don't want to keep throwing money out the window.

txcamper I wish insurance companies were not the only ones taking over our lives. Drs on the other hand harass us to have proceedures then when they don't find an answer tell us we are "percieving" it.

Read Jimmo case from 2013. The "progress" criterion noted above was held to be illegal and improper. The case was reviewed in 2016 and Medicare is too put forth a better effort to make certain that contractors, providers and reviewers understand that the criterion is "need for skilled services" NOT "progress" potential or perfomance. Many Medicare recipients are not receiving the care they need. "Coverage for such skilled therapy services does not turn on the presence or absence of a beneficiary’s potential for improvement from therapy services, but rather on the beneficiary’s need for skilled care. Therapy services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist. (See 42CFR §409.32) These skilled services may be necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.” Sec. 30.4 of Chapter 8 of the Medicare Manual as amended in January 2014.

"On January 24, 2013, the U. S. District Court for the District of Vermont approved a settlement agreement in the case of Jimmo v. Sebelius, in which the plaintiffs alleged that Medicare contractors were inappropriately applying an “Improvement Standard” in making claims determinations for Medicare coverage involving skilled care (e.g., the skilled nursing facility (SNF), home health (HH), and outpatient therapy (OPT) benefits).”

https://www.cms.gov/medicare/medicare-fee-for-service-payment/SNFPPS/downloads/jimmo-factsheet.pdf

I have gone through this several times with my Mom, and she is currently getting PT in a nursing facility. The whole thing seems to be a race against the time the insurance and medicare allows. Once Mom gets home she has a home PT person come in 2x a week, but I have been told to do the sets of exercises with her myself on a daily, or sometimes twice daily basis. This gets hard to do sometimes, and most patients plateau out at a certain level or quit the exercises entirely.

For help, go to: http://www.medicareadvocacy.org/wp-content/uploads/2014/01/Jimmo-Postcard-General.pdf