Discharge appeals for the elderly prove difficult and must be filed quickly


The old man slept peacefully while his daughter sat by her hospital bed. Suddenly, an assistant came in and announced that a move was imminent.

“Your time here is up,” Bonnie Miller Rubin remembers the help explaining. “He’s going to a nursing home.”

It was 9 p.m. and Rubin’s 91-year-old father had been asleep for several hours. “I said, ‘Are you kidding me?'” Rubin recalled.

“I felt helpless,” she said, remembering her alarm that cold night three years ago. “What rights did I have? »

In fact, Rubin could have filed a “quick appeal” of his father’s pending discharge with a Medicare quality improvement organization. If she had telephoned the scene, her father would have remained in hospital until an independent doctor examined his situation.

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Any older person admitted to a hospital as an inpatient has the right to challenge a discharge if they do not feel ready to leave. But few people understand the process that is involved.

Often seniors and their families are taken by surprise when a hospital transfer is imminent.

“People don’t understand how fast things are going,” said Trish Colucci, senior care manager at Peace Aging Care Experts in Flanders, NJ. “There is tremendous pressure on discharge teams to discharge patients.”

After a lawsuit accusing Medicare of not giving beneficiaries adequate notice of the right to appeal pending discharges, the government issued new regulations on the process a decade ago. Here’s how the so-called “speed dials” are supposed to work:

Know your rights. Every older person admitted to hospital must receive written notice of their rights – including the right to appeal planned discharges – within two days. If you stay in the hospital for at least five days, you should get a second opinion before you are discharged.

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This “Important Medicare Message” will give you the name and a phone number of your Medicare Quality Improvement Organization (QIO) – an entity responsible for handling prompt calls as well as other issues, such as complaints regarding the quality of care.

QIOs serve seniors with traditional health insurance as well as seniors with managed care-style Medicare Advantage plans. Livanta is the QIO for seniors with Medicare who live in the Northeast and West Coast. KEPRO covers the rest of the country.

Rubin does not recall receiving these notices from Evanston Hospital, just outside Chicago, where his father was being treated for respiratory distress. But Jim Anthony, a hospital spokesman, said the medical center still distributes them, as needed.

The medical center began planning for the older man’s transition to a nursing home “on the day of his admission, with the knowledge of the family,” Anthony said.

The bottom line: Read all the materials given to you at the hospital. Don’t assume you can put this off.

Initiate an appeal. If you don’t feel ready to leave the hospital, call the QIO and explain that you are filing a quick appeal of a pending discharge. You can call during the day or at night until shortly before midnight on the day the discharge was supposed to occur.

If someone isn’t looking after the phones — QIOs are open 9 a.m. to 5 p.m. during the work week and 11 a.m. to 3 p.m. on weekends and holidays — leave a message explaining your situation.

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A family member or caregiver can initiate the process if a patient is unable to do so. But he may subsequently have to complete a form stating that he can act as the patient’s representative.

Only seniors admitted to hospital are eligible for this appeal process. Patients in “observation status” have a separate appeal process. So be sure to clarify your status often, it might not be clear.

Hold on. Once a Quick Appeal has been filed, you cannot be transferred from the hospital again until it is resolved. Usually it takes about two days.

You also cannot be billed for extra time you spend in hospital, although coinsurance payments and deductibles still apply.

The hospital will send a copy of your records to the QIO for review by an independent medical reviewer. You have the right to see these documents, if you wish. The QIO will contact you and inquire about your leave issues.

If the QIO determines that a discharge is appropriate, you can stay in the hospital until noon the next day at no additional cost. If the QIO overrules the hospital’s decision, you can stay until another discharge is offered.

The standard? Medical care in hospital should be deemed medically necessary by your doctor.

If you’re stabilized, with no symptoms such as fever, difficulty breathing or a festering wound, you’ll likely be considered ready for transfer, said Anne Sansevero, a registered nurse and aging life care specialist in New York City.

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Stay informed. It’s a good idea to ask your doctor every day “Is there an update on how long I’m likely to be here?” so you don’t find yourself “in a last-minute situation,” said Liz Barlowe, care manager in Seminole, Florida.

If the hospital has not adequately addressed your need for a “safe discharge”, you may have grounds to challenge their decision.

Barlowe described a 78-year-old customer who fell and broke her hip while visiting her son and daughter. Preparing for surgery, scans showed the woman had masses in her uterus and pelvis – cancer.

After the hip surgery, hospital staff said they could not get a gynecological oncologist to consult on the elderly woman’s case and recommended that she be sent to a rehabilitation center.

Barlowe immediately contacted KEPRO, which reversed the hospital’s decision. Instead, the QIO medical examiner ordered the patient to remain there until a cancer specialist provides a consultation and helps design a care plan.

QIO’s intervention bought the family an additional 48 hours, during which time they were able to find a facility in Miami that could provide chemotherapy as well as rehabilitation for the woman’s hip. And the patient was able to rest and regain strength.

Quick appeals similarly exist for palliative care, home care, skilled nursing, and rehabilitation services, but the rules and timelines involved differ slightly.

KHN’s coverage related to aging and improving care for the elderly is supported by the John A. Hartford Foundation.

Twitter: @HC_Finance

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