The Safe Discharge Plan

As the baby boomers enter their golden years, they are facing a catch-22: while they can expect to live longer due to advances in medicine, they will also be increasingly facing situations where they are not able to care for themselves. This can be a terrifying realization, especially for those who do not have the luxury of a close, living relative dedicated to their healthcare.

Clinical Scenario

Ms S. is an 84-year-old female with past medical history of hypertension who is bought to the emergency department after a fall. Extensive imaging done in the ED including CT head, CT c-spine, and hip and pelvis radiographs are negative for any acute traumatic injury. Her vital signs and laboratory evaluation, including a complete blood count, chemistry panel, and urinalysis are normal and do not point to any etiology that may have predisposed her to have the fall. Additionally, the history is not suggestive of syncope. When asked to describe what may have caused the fall, she states, "I don't know. I've been feeling weak and must have just tripped and fell". Ms S. also tells the ED staff that this is her fifth fall in the past two weeks. She then states, "I don't think I can manage alone at home. Can't you set me up with a rehab or a nursing home for a short while? I have Medicare..." It is determined that it would be unsafe to send Ms. S. back home alone, and she is admitted to the general medicine service for placement. The next morning, when her case is reviewed by case management, it is determined that she does not meet criteria for an inpatient admission. She is admitted under observation status. What does this mean for Ms S.?

When a patient is admitted to the hospital, there is a team assigned (case managers or social workers) to review the patient case against a complex set of criteria according to their institutional-based Utilization Review guidelines. These are primarily driven by Medicare (and adopted by most insurance plans) and are used to determine whether a patient meets criteria for inpatient admission. While Medicaid has a set reimbursement it pays per admission (albeit very low), Medicare retrospectively reviews cases and reimburses the institution based on the acuity and level of admission (critical, acute inpatient, observation). This not only affects the amount the institution will collect for every patient admission and hospital stay, it can also affect the post-discharge disposition, specifically whether Medicare will cover the post discharge nursing or rehabilitation needs. For a patient such as Ms. S., who has Medicare or a similar private insurance, she cannot "tap" into her skilled nursing or rehabilitation benefits; these only come into effect after a qualifying "inpatient" hospital stay of a minimum of three days. What qualifies one for an inpatient admission versus observation status can be very complicated and is institution dependent. In today's world, where Medicare is facing increasing economic pressure and hospitals are trying to cut costs and maximize their reimbursement for services, many institutions have adopted strict guidelines as to what qualifies as inpatient versus observation. Here are a few examples: a patient who is admitted with a fall and found to have a subdural hematoma or a fracture will qualify as inpatient whereas the patient who has repeated falls at home but no fracture will only qualify as observation, even though she may not be safe to go home and the physical therapist recommends rehabilitation services. A patient who comes to ER with nausea/vomiting and found to have UTI will only meet inpatient criteria if he/she is given IV antibiotics; if this patient was admitted for weakness, inability to stand up, persistent nausea, and abdominal pain, but was given oral antibiotics, he/she is considered to be observation status. Last example, a patient with progressive dementia (Mr. L.) who has been found wandering, cannot reliably take his meds, does not regularly shower, or remember to eat his meals, is no doubt unable to care for himself will be admitted under observation, unless he has any acute illness that requires IV medications, aggressive fluids, further work-up, or consultation.

As mentioned above, if Ms. S.'s hospital admission had met inpatient criteria, she could have used her Medicare or private insurance benefits for a short stay at a nursing home for skilled nursing requirements or rehabilitation services. This is usually covered fully (after deductible) by Medicare Part A for a limited amount of days (approx 20). If Ms S. continues to require these services, she would pay a daily amount (approx $130) with Medicare covering the rest for up to 100 days. After this, Ms. S. would be fully responsible to pay for her stay. Unfortunately for Ms. S., since she is admitted under observation, she will be responsible for paying for the entire stay out of pocket from the beginning. This can be quite costly, and many skilled nursing facilities require an upfront payment upwards of $10,000 before accepting the patient. Imagine the cost for someone like Mr. L, who will likely need to spend the rest of his life at a skilled nursing facility. As you can imagine, this can be quite distressing for anyone, especially our elderly patients who have spent their working lives paying Medicare taxes. Of note, this is not an issue for patients with multiple medical problems (chronic disability), low income, or limited assets who are eligible for and enrolled in Medicaid (National Health Care Program). For these patients, long term care is fully covered in Medicaid qualifying nursing homes. This is also not an issue for those who opt for a "Managed Medicare" product, in which their Medicare dollars are given to and managed by a private health care insurance such as Blue Cross, Harvard Pilgrim, United, etc. By allowing such private insurance companies to manage their Medicare funds, patients benefit from having less restrictions for qualigying to recieve post-discharge services (ie, don't have to be "inpatient" nor do they need "three day stay"), but this comes at the cost of having more restrictions on medical coverage (need preauthorizations for everything, referral circle is limited, etc). Also, the coverage once again is limited to short term post discharge services similar to Medicare coverage.

While in an ideal world, Medicare would change their coverage to offer at least short term rehabilitation, skilled nursing, home services for all their patients who require these services, this is unlikely to happen any time soon, especially with the growing concerns over Medicare and the national health care program (Medicaid) inching towards bankruptcy. Along the same lines, it would be even more unrealistic to expect coverage for long term skilled nursing placement. So what are the options for this subgroup of elderly patients? Should they have to sell all of their assets and empty their bank accounts to be able to afford home services or skilled nursing care? Do they rely on family members to cover these costs? What if they don't have any living relatives or close friends?

I, for one, don’t have the answers to these questions. I believe this is the case for the majority of young hospitalists who have not received much training in the area of health care policy during residency. In my practice, I am faced with at least one such situation every couple of days, and it is definitely one of the most unsettling and unrewarding experiences. I recently had a discussion with one of my collegues, mostly to vent out my frustration over these situations (thank you, Nick Nace). He introduced me to the concept of Long Term Care Insurance. This is a supplemental insurance designed to cover the costs of long term needs (ie, home care to assist with activities of daily living, adult day care, assisted living services, and nursing home care), which are not covered by standard health insurance policies or Medicare (beyond 100 days). With patients living longer these days and with more chronic illnesses, along with increasing health care costs and restrictions on coverage, the chance that they will need to use one of these resources at some point is quite high. Some people are under the false impression that the government will cover these needs when the time comes. Although Medicaid can cover long term care needs, it requires one to "spend down" your savings and assets before qualifying. Thus, one of the main attractions to buying to Long Term Care Insurance is protection of assets.

When should one consider buying Long Term Care Insurance? Definitely not when he/she is 70-80 years old and has chronic medical illnesses, as the premiums will be very high. The ideal time is middle age, when he/she has fewer medical illnesses and, thus, can lock in lower premiums. Since this is a voluntary supplemental insurance, it is not clear how the option is bought to a person's attention in the first place. Unfortunately, there are many patients who have never heard of this early enough. Certainly, at the time of admission is too late. The truth of the matter is, even if this option is introduced to all patients at an earlier age, it is unlikely that many will have the foresight to make an investment that pertains to their distant future. I wonder if we should start to think about such long term coverage more as a requirement than an option.

As in the aforementioned cases, some patients may be victims of a progressive disease and some simply of old age. Without any illness causing sudden decompensation, these patients generally do not qualify for an inpatient admission. Whereas Ms. S. may benefit from short rehabilitation stay, Mr. L. clearly appears to be destined for more long term skilled nursing home placement. In both cases, the patients were admitted under observation and thus did not qualify for the level of post discharge services they required. They remained in the hospital for several days until we were able to set up the maximum home services covered by their health care plan and contact any close friends or relatives to donate their time in order to formulate the safest discharge plan.

As hospitalists caring for an ever-growing population of elderly patients, these cases are all too familiar and quite unsettling. I would sleep a lot better at night knowing that I have a safe discharge plan for my patients.