3-25-2022 Finally, an acceptable next step

(Tricia)

As Marilyn noted, it has been a stressful few days. Because three skilled nursing facilities had agreed to accept Linda, Missouri-Baptist was set on discharging Linda yesterday. It didn't matter that all three were one-star-rated on Medicare.gov and were woefully understaffed (according to Medicare's inspections), or that one had an abuse allegation. All had received abysmal user reviews. It didn't matter that we did not want to have Linda complete her rehab in such facilities, or that we had zero faith that any of the three would be able to manage the every-four-hour (Q4) antibiotic regimen that had been the obstacle for so many other facilities. As far as Mo-Bap was concerned, a facility had accepted her and that was that. 

I felt I had no choice but to appeal the discharge, just to buy us some time. If you are in the hospital as a Medicare-covered patient, the case workers are required by law to tell you every week you're there that Medicare gives you the right to appeal a discharge if you believe it to be premature or unsafe. I had been getting those boilerplate calls, but I had largely dismissed them as mere bookkeeping. I did not think I'd actually have to exercise that right!

Yesterday, I called in the emergency appeal to the number provided--that halted the hospital's plan to discharge Linda, albeit temporarily. This was not without risk. If you appeal a hospital discharge under Medicare and that appeal is denied, the patient must be discharged by noon the next day, whether she has a place to go or not. Otherwise, the hospital will begin charging the patient, not the insurance company, for the cost of every day she's in the hospital after the denial has been communicated. But I just hoped that if we had a couple more days, we could make something happen.

After I finished the phone call to make the appeal, I started making phone calls to anyone I thought could help--the two elder care consultants we've been working with, a palliative care consultant I have been in contact with, and facilities that were not among the 39 (yes, THIRTY-NINE) that Mo-Bap had contacted. That meant we were looking at facilities in Illinois, farther south, and farther west in the St. Louis area. Marilyn also spoke to friends she knew in Illinois who recommended one facility in Belleville very highly.

Meanwhile, the case worker at Mo-Bap yesterday gave me Linda's discharge papers, pending the appeal outcome. After I asked her to send requests to two other skilled nursing options, she came back with a printout of all the facilities that they had contacted on March 17, so I could see the reasons these facilities would not accept Linda. As I read through it, I noticed two facilities--Barnes-Jewish Extended Care and The Quarters at Des Peres--had said "no." However, in the notes, each had written something to the effect of "But check with us next week, because we could have availability then." Both were three-star rated by Medicare, and both had far better reviews.

Those two responses stopped me--at no point last week, when these responses came in, did the case worker let me know there were any "maybe, check back" responses from better, closer facilities.  I immediately called her and left her a message asking about these two facilities yesterday morning, but I did not hear back from her for the rest of the day. 

After I left the hospital at around 3:30, I had settled nothing. I truly didn't know what to do next. Just as I was heading home, the admissions director of one of the potential one-star facilities on the table, Green Park Senior Living in South County, called me. She said she was returning my call, but I frankly have no recollection of having called her!  Still, it seemed serendipitous. Of the three options we had, we had determined Green Park to be the "least worst." So I quickly scheduled a tour with her, hoping I could get there before she left for the day at 4:30. I hoped that a tour would lessen my concerns. 

Green Park was about a 30-minute drive away. When I got there, I was glad to see that the facility was updated, but the admissions director seemed very uninformed. She didn't know how many therapists they had on staff or what the nurse-to-resident ratio was, for example. I was unable to meet any of the therapists, and I didn't see a single nurse in the hallways or working with residents. It was just odd. It could have been empty because it was around dinner time, but I still left feeling no better about the prospect of placing Linda there.

Earlier yesterday, I also left a message for the infectious disease doctor, through one of the nurses, asking if there was any way we could adjust the Q4 antibiotics to something that would be more manageable at a skilled nursing facility. The palliative care consultant whom I'd spoken to had let me know that almost no SNF would agree to such a regimen of intravenous antibiotics because of staffing concerns. She suggested that if I could get the doctor to change the drug regimen to an 8- or 12-hour delivery, many more options would open up. So, I wanted to talk to Dr. C. to see if there were any other options.

However, the infectious disease doctor, who normally comes to Linda's room every morning, did not come by in person yesterday for whatever reason. Instead, he sent the hospitalist to come in and tell me that he "refused to revisit the antibiotics."  It didn't matter that I had no faith in the facilities that had accepted her to administer these antibiotics on his required schedule.

This morning, I called and spoke to the admissions director at one last facility, Nazareth Living Center in South County, to see if there might be any possibility there. This facility had turned Linda down initially, but had asked Mo-Bap for more information after the hospital sent a second inquiry. She said that while she thought Linda's needs "exceeded their capacity of care" (the standard phrasing), she was very sympathetic and said that she would ask the nursing staff if there was any room at all to accept Linda.

However, about ten minutes after I got off the phone with her, my phone rang, and it was Mo-Bap's case worker.  She had called Barnes-Jewish Extended Care, and a bed was now available. I have no idea whether the case worker had called them before, or if she only called them because of my phone message yesterday--I suspect the latter, but I have no way of knowing. Either way, the facility is closer to us, higher rated, more completely staffed, and more equipped to handle the Q4 antibiotics. I immediately told her that facility would be acceptable.

Then there was the matter of my appeal of discharge. It had bought me the appropriate amount of time, but the next problem was the timing of the insurance's approval of Barnes-Jewish and the return of the denial of my appeal.  The case worker said that it was unlikely that Barnes-Jewish would be able to receive approval from Anthem before Monday. If the appeal denial came in before that, we would be responsible for paying for the hospital room for at least one to two days. 

But I didn't have long to worry. Somehow, the hospital, Barnes, and the insurance company were able to push through the approval quickly. Insurance was approved by this afternoon, and Linda will be discharged tomorrow at 1:30.  It has been such a long a fight, but I feel like Barnes Jewish Extended Care will be a much better place for Linda to be than the other options. 

It has been nearly a month since Linda was first admitted to the hospital, and this all has been so exhausting. As Marilyn noted, it really did come down to the wire. But now that we finally have an acceptable discharge and subsequent care plan, I am beyond relieved.

(Update: They called with the denial of the appeal later this afternoon. If the insurance hadn’t come through with the approval in time, we would have ended up with an expensive hospital bill—whew!)