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Where do we go from here? Discharge planning after your senior parent’s ER visit

After all of the tests and waiting and treatments are completed, it is time to decide what the next steps are for your Mom or Dad. Here are some possible scenarios.

Scenario 1: The doctor wants your father to stay in the hospital

Ø The first question is … Why?

If it is for a blood test or x-ray that is needed tomorrow, can it be arranged and completed on an outpatient basis?
If it is because he should not be alone for the first 24 hours, can your dad go home with you or can you stay with him?
Does he live in an assisted living facility where you can arrange some nursing care and monitoring?
Can he be sent home with in-home supports you can arrange, such as private home health aides?

Ø The second question is … Will he be admitted or placed in an observation bed?

Keeping your father in the hospital does not necessarily mean that he is going to be admitted!
If the doctor is planning to place your father in an observation bed that means that:

– MEDICARE WILL NOT PAY FOR ANY OF THE HOSPITAL BILLS INCURRED ONCE THE ER TREATMENT IS COMPLETED, AND

– IF YOUR FATHER HAS TO BE TRANSFERRED TO A SKILLED NURSING FACILITY FROM THE HOSPITAL FOR REHABILITATION WITHOUT BEING ADMITTED, MEDICARE WILL NOT PAY FOR ANY OF THE BILLS FROM THE REHAB FACILITY.

If the doctor is planning to admit your father to the hospital, that means that Medicare will most likely pay for his hospital bills, as long as it is a medically necessary admission.

Scenario 2: The doctor wants to discharge your mother

Ø Where will your mother go?

If she lives alone in an apartment or house

– Does she need someone to be with her for a day, a week, or longer?

– Does she have stairs to get to her bedroom or bathroom that are now an obstacle?

If she lives in an assisted living facility, do you need to contact them for added services and supports to be in place before she returns home?

– Can they have these supports available to her immediately upon her return, or does it take some time for them to arrange theses?

Before your parent leaves the ER

Regardless of where your parent will be going, there are several issues you need to discuss with the doctor before your parent leaves the ER.

Need assistance? Wondering what the right thing to do is? Give us a call!

In good health,

The Health Champion Team

Is Mom OK?

Are you noticing that your mom or dad is starting to struggle with everyday activities?

Are they not bathing or showering as often as you think they should?

Is their refrigerator full of food that should have been discarded weeks ago?

Is your once meticulous mom or dad wearing clothing with food spots all over the front of their shirt?

Are you worried that they are not eating well and appear to be losing weight?

Do they not tell you that they have fallen or went to emergency room until days later?

You are not alone. Over 22 million households in the U.S. are caring for a friend or relative aged 50 years or older. So why is it so difficult?

Our older adults are trying to cope with a world that is becoming more complex while their world is growing smaller, confusing and more difficult to manage.

Consider this:

You are dealing with people have always been independent and desperately trying to remain so
What you may think is the best solution for a problem may be very difficult for them to understand or do
They are trying very hard not to be a burden to anyone or interfere with your busy life
They may be embarrassed to ask for help
Your roles are changing you are becoming the caretaker, a role they are used to having

There are no good answers. We are all dealing with the frustration of trying to keep them safe and yet maintain their independence. They are dealing with the frustration of knowing that they can no longer do what they used do. So we all end up frustrated!

Engaging an expert who is not a family member to have the frank discussions makes it easier for everyone. It is a relief to discuss your concerns with someone who knows what supports are available, has the expertise to offer suggestions and solutions, and knows how to navigate the system on your behalf.

So arrange a time and place when everyone can come together and start the tough discussions. It will most likely take several meetings over time, but be patient, listen to each other, and let your expert guide you. You are essentially looking for short term solutions and a long term plan. Document the plan and make sure that family members are aware of the plan and are on board. Issues and disagreements about a plan of care for Mom or Dad should be worked out before the plan needs to be implemented.

Not sure where to begin? Some excellent resources can be found on the following websites:

Elder Care Matters www.eldercarematters.com;

National Alliance for Caregiving www.caregiving.org

National Association of Professional Geriatric Care Managers wwwcaremanager.org

In good health,

The Health Champion Team

www.healthchampion.net

Inpatient or Outpatient ?

If you are a Medicare Beneficiary, knowing your patient status during a hospital or emergency room visit will impact reimbursement and your out of pocket expenses.

If you have a loved one who has recently been to the ER and stayed overnight in the hospital you need to be aware of the following:

Your hospital status (whether you are considered an inpatient or an outpatient) depends on whether or not your physician has written orders for an inpatient admission. In other words, your doctor has evaluated your physical status and made a determination that you need to be admitted to the hospital. Your head on the hospital pillow or lying in a bed in a hospital room does not mean you have been admitted. Only having a written physician hospital admission orders makes your status an inpatient.

You are an outpatient if you getting emergency services, being watched or observed or having outpatient tests, your status is considered outpatient.

Consider this…You go the emergency room with chest pain and the hospital keeps you for 2 nights for observation – your status is Outpatient and reimbursement is under Part B. Part B covers your physician services and hospital outpatient services such as lab tests. Part B has a deductible and coinsurance. Part A in this situation will not reimbursement or pay for any of the services.

Depending on the amount of services your balance at the hospital can add up. To avoid any financial surprises, it is best to verify your status and if possible keep a log of services rendered.

For more information check the Medicare website, www.medicare.gov/publications

Could Your Family Benefit from a Geriatric Case Manager?

For those of us in the so-called sandwich generation, the following scenario is being played out repeatedly.

Mom and Dad are doing just fine, living a good life in __________ (insert state, town). Mom or Dad needed a __________ (hip, knee, valve replacement, etc.) They made it through the surgery just fine, but now they are not bouncing back to what was their pre-surgical state. You are nervous that something is wrong – you are not sure what – but as you are not living nearby, you need HELP!

If your parents are still living independently, one option is to find a local geriatric case manager who can make a home visit and assess the situation. According to the National Association of Geriatric Case Managers, a geriatric case manager is a health and human services specialist who helps families caring for older relatives. The GCM is trained and experienced in any of several fields related to care management, including nursing, gerontology, social work, or psychology, and can:

Conduct care-planning assessments to identify problems and to provide solutions.
Screen, arrange, and monitor in-home help.
Provide short- or long-term eldercare assistance for those engaged in local or long-distance caregiving.

In short, a geriatric case manager can be an excellent resource. To find a local geriatric case manager, you can check the following resources:

Health Champion

National Association of Professional Geriatric Case Managers

AdvoConnection

Top 5 Mistakes You Can Make During Open Enrollment

Now that summer is ending and school is beginning, it won’t be long before the busy open enrollment season is upon us. While most of us don’t look forward to wading through benefits descriptions, it’s important to put those feelings aside and invest some thought in the process. Taking time to study your options now could not only save you money, but also affect your health care choices for the coming year.

5 Mistakes to Avoid when Choosing Your Health Coverage.

Buying on price alone. Finding affordable insurance is getting harder and harder, but buying on price alone is often a mistake. Your monthly premium may be low, but can you really afford that high a deductible? Buying a high deductible plan under the assumption that you are healthy and never need to use doctors is risky. Are you prepared to pay the deductible if the need arises? Can you afford the cost shares that may kick in after the deductible is met? If your employer offers worksheets or modelers for comparing the available plans, take advantage of them and do the math.
Not considering your family’s situation. Of course, you can’t predict everything that might happen, but you can look at your current health status. If someone in your family has a medical condition, you can take their care plan – upcoming tests, specialist visits, and medications – into account. You will also want to look at your values and attitudes. If you like to be in charge of your care, you might be willing to pay extra for a plan that doesn’t require referrals to specialists.
Not verifying your providers’ participation status with your health plan. Providers who are considered in plan have a contract. Contracts change and it is not unusual to have providers cancel participation with a health plan. Just because your provider was “in network” and “participating” last year doesn’t necessarily make it so this year. Call the health plan and call your doc to verify. Check your health plan’s website for an up-to-date list of participating providers.
Renewing into the same benefit plan design. Benefit plans change each year. There may be new plan limits and exclusions. Don’t assume nothing has changed. Pay particular attention to your prescription benefit. Drugs lists often change at the time of open enrollment – impacting the tier that drug is on and how much you will pay out of pocket next time you renew your prescription.
Not taking advantage of opportunities to offset cost sharing, if offered. A Flexible Spending Account lets you to put aside pre-tax dollars to use for eligible medical expenses. If you can predict some of your deductible and copayment expenses for the coming year (based on your health needs and the plan design you choose) and put them in an FSA, you can save around 25% on your out-of-pocket expenses by paying with pre-tax dollars.

Perhaps the most important thing you can do is to ask questions. If you don’t understand a benefit offering, ask your Human Resources department. If you’re not sure how much you spent this year, see if you can download your claim history from your health plan’s web site or request a report. Make an informed decision this fall, so you can use your plan with confidence in 2012.

Leaving the Hospital – Part Two

After reading the true stories in last week’s blog (part one), you must be wondering how to prevent discharge horrors. You realize that the term “discharge planning” is, in many instances, an oxymoron.

The discharge part is true. The planning? A little less so. It’s typically brief and fraught with gaps in communication between hospital caregivers and family members who often take over that role. All you want to do is get your loved one home. But you also want to know what you need to know. And in clear, precise terms.

Ask for a preliminary discharge meeting before the day of discharge. This allows time for you to process information and identify issues or gaps in the planning. Will you need to rent a hospital bed, for instance? Do you need to arrange for outside care? These things take time. What services and equipment will be covered by insurance?

Get a list of medications your loved one is currently taking; compare it to the ones taken prior to admission. Make sure you understand what’s been added, changed or modified. To avoid confusion, or waiting around on discharge day, call your pharmacy in advance to see if they stock the new prescriptions.

Your Discharge Planning Meeting should be with health care professionals (usually a social worker or nurse, or both) in which they:

Assess the patient’s needs: physical, social, and emotional.
Clarify the discharge plan so that the patient and family members understand each element.
Identify what resources (family, friends, community) are available to assist the patient in meeting identified needs. Are these resources sufficient?
Educate family members and friends on their new responsibilities.
Monitor and modify the plan, as appropriate, and in response to family/caregiver feedback before discharge.

Remember: You don’t have to accept a discharge plan. Express your concerns. Don’t leave without a full understanding and comfort level of your loved one’s condition and your role as caregiver. And if you feel anxious, or you’re worried about understanding everything, bring along an advocate as a “second pair of ears.”

Who’s On First?

Following up on our blog from a few weeks ago — having “double the benefits” with two working spouses and two health plans — we’re adding Medicare to the mix.

Sample Scenario —

Husband: takes retirement, is 65 or older (and/or is disabled), and has Medicare as his primary health insurance coverage.

Wife: continues working, has employer based health care benefits for her and her husband.

He goes to the doctor and assumes Medicare will cover the visit and any treatments or tests. But it ain’t necessarily so! And that’s why he MUST let his health-care providers know about his wife’s employer-based plan.

In a nutshell . . .

As a non-active employee (an individual who is retired, on COBRA or Long Term Disability), the husband would typically be covered by Medicare as his primary insurance. However, as a dependent on his wife’s insurance, the size of her employer’s group will determine primacy: if there are fewer than 20 employees, Medicare pays first; more than 20, her health insurance pays first and Medicare pays second.

The rules for coordination can be complex. Keep your health plan administrators informed of changes or other coverage. Make sure your doctors know about the dual coverage and present both cards at the time of your visit.

Questions? That’s our specialty — finding answers, determining solutions. So, call if you need us. You can also contact the Medicare Coordination of Benefits Contractor at 1-800-999-1118.

Meanwhile, just remember, the answer to Who’s on First? can be a tricky one!

Choosing the Right Health Plan- Benefits by Design -

Continuing last week’s discussion, Choosing the Right Health Plan, let’s look at how the actual Benefit Design can — and should — shape your purchasing decision.

When we say benefit design, we’re simply acknowledging that medical insurance plans come in various shapes and sizes; you need to pick one that fits you and your family.

What’s in a Name?

Everything. The name itself often represents the type of product, reflects plan rules or highlights a unique element. Example: HDHP stands for “high deductible health plan!”

HMO, PCP, Gatekeeper — these names are associated with benefit designs from health plans versus insurance companies. They generally require a referral from a primary care physician before you see a specialist. Does that work for you? Are you willing to engage with a primary care physician as part of your health care team? Open Access, on the other hand, typically means you don’t need a referral from a primary care physician to see a specialist.

Points of Service

Before purchasing a health plan, make sure you understand how it’s designed in terms of service. For instance, will you be covered — to some degree, at least — if you see a non-participating doctor?

Warning: if you call a doctor’s office to see if they participate with your insurance and you get this response, “We accept all insurance” DO NOT think it means they participate with your plan. It simply means they’re willing to accept a check from anyone. Ask more questions.

Need physical therapy? Want to see a chiropractor? Make sure these services are covered and if there are limits on visits. It’s not unusual to see benefit designs with limited coverage for these services.

There’s a lot to consider when choosing a heath plan. And the wrong decision can be costly. Check with your state’s Department of Insurance website for a list of all licensed insurance companies and health plans doing business in your state. See what’s available. And when in doubt, consult an expert for advice.

-end-

We’re New And We’re Here to Stay

“You’re a WHAT? And you do WHAT?”

It’s a typical a response from physicians who haven’t scanned the forest of health care lately to see there’s a new animal in their midst. That animal goes by the general name of “health care advocate” and the specific name of Health Champion. Our general nature is to help, guide and support individuals lost in the maze of decisions, diagnosis and insurance benefits.

Here’s an example —

The Call: We were recently retained by a family to help navigate their sister’s s journey through multiple myeloma. They called as she was recovering from surgery, having experienced the disease’s wrath in the form of bony metastases.

The Need: On a very basic level, they were seeking clarity about their sister’s condition, needing a greater understanding from the surgeon and oncologist regarding prognosis and overall treatment plan.

The Approach: We quickly established contact with their sister’s medical providers, providing each office with signed HIPAA and Representative forms, so that physicians could speak freely with us. The goal was to collect information from the various sources and then connect the dots for our client, explaining complicated information in a clear, accessible manner.

The Result: Our client and her family felt fully informed and, thereby, empowered to make smart decisions regarding the recommended treatment plan.

The Response: Because we’re newcomers, medical colleagues are often surprised by our presence. Who are we . . .where did we come from . . . what’s our intention? But, seeing that we come in peace, they’re collaborative, professional and open to the concept of advocacy. And then there are those few defensive physicians, wary of our intentions, certain our goal is to undermine and undercut, to add an unneeded layer to an already complex system. That is so not so!

They’re right about one thing: The health care system is definitely layered and complex. It’s fragmented, confusing and overwhelming. It isn’t easy being a physician in today’s insurance-based model. And it’s not easy being a patient or consumer. That’s exactly why we exist.

Our role is to support our clients and their health care team by closing gaps in communication and planning, by explaining and reinforcing the difficult messages they have may have been told, but didn’t understand, and were too embarrassed to ask for clarification.

While health care reform may be upon us, it isn’t going to fix the very things that health care advocates are hired to do. We’re on the scene, and we’re here to stay.

The Test Gets Authorized

“Why won’t my insurance cover a CT Scan of my heart that the doctor says I need.”

That was the call we received recently from a woman who was confused, upset, and uncertain about getting the care she needed. She’d had questionable results from both her stress test and her cardiologist recommended that she follow up with a CT scan ( to be exact, her doc wanted a CT scan of her coronary arteries, affectionately known as code 0146T).

But her insurance company refused to authorize this critical test.

Why? Was there anything we could do to help?

We went right to work and here’s what we discovered:

The cardiologist’s office followed protocol by calling the woman’s health plan and submitting the required information. However, what was submitted didn’t meet her insurance guidelines.
We obtained a copy of the company’s guidelines for radiology, and then compared the information sent by the doctor.
We then interviewed the woman and discovered she’d neglected to mention certain symptoms to her doctor.
We discussed those symptoms with the doctor’s office; they updated the information, sent it off for insurance review, and the test was authorized.

Lessons learned…

Always ask why. If you need a test/procedure and your health plan won’t authorize it, ask for clarification. You’re entitled to a copy of the guidelines used to make the decision.
Don’t assume that your doctor’s office will engage with the health plan on your behalf. Stay on top of the situation.
Review the information and symptoms you’ve shared with your doctor and see if there’s more that might be helpful.
If you’re having trouble getting answers, enlist help. Don’t just settle for “no.”
Realize that by enlisting a private advocate, you save time and money and get results.

Health Champion Blog

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