In May, 2017 Hawaii’s station KITV reported that caregivers were meeting with legislators to try to improve hospital discharge planning. According to the television channel, patients were being released from the hospital with the expectation that elderly caregivers would be able to meet the care needs of other, similarly elderly, patients. “They say unpaid care giving in Hawaii falls on the shoulders of women who experience most of the physical, emotional and financial impacts of care giving,” the station reported. The organizers contend that they do not get enough training, and that they just plain don’t get enough help.
Organizers Ai-jen Poo and Cathy Betts are advocating for the Kupuna Caregivers Assistance bill. If passed, the bill would give qualifying caregivers vouchers to help pay for adult day care, homemaker services, temporary relief, transportation, and personal care.
This is not a problem unique to Hawaii. Even in paradise, there’s no pot-of-gold at the end of the rainbow for elderly caregivers trying to help their loved ones. Have you ever picked up a sick relative at the hospital only to discover that the hospital expects the mythical “family” to take care of that person? I have, and found that many of the procedures that health care professionals take for granted are way out of the comfort zone of the average person. And it’s not just expertise. There is often no warning that the recently released person needs constant care for 24-hours to a week. With an aging population the assumption that an elderly partner is physically capable of caring for an ill spouse may be erroneous.
I asked my sister, Carolann Cody, who is a manager for a home health care agency, to provide some answers to questions about hospital release policies. Below are her answers to my queries.
1) Different hospitals assign discharge planning responsibilities differently, but, in general, the discharge planner or care coördinator would meet with the patient to discuss needs and resources. There is a document that Medicare requires for notification of discharge and that spells out the patient’s right to dispute the release. There is no particular form to sign if the patient has private insurance, but the patient should be given a discharge-instruction sheet at time of discharge to tell he or she what to do for follow-up.
2) There is no guarantee that an elderly person would not be expected to provide care. We see that fairly often. Hopefully they have resources to hire additional help. No insurance covers 24-hour care at home. Most insurance plans follow Medicare guidelines which, in a nutshell, are as follows:
Insurance will pay for intermittent care by a skilled nurse, physical therapist, or speech therapist if that is ordered by a physician and is medically necessary.
The patient must be home-bound to receive such care. If the patient qualifies for additional services, he or she may receive HHA (Home Health Aide) services for personal care, OT (Occupational Therapy), and/or MSW (Social Worker) help.
The aide generally spends about an hour several days a week to provide personal care and do some light ancillary patient-directed care (load of laundry, change linen, wash dishes, or make the patient a light meal). The home-care social worker would help the patient explore additional resources, and help with planning and assist the patient and family with placement in a nursing home if that is needed. In California, MediCal, if someone is eligible, does have a program called “In Home Support Services” that pays for attendant-level assistance at home. It’s never as many hours as someone needs, and is basically a minimum wage position, not skilled nursing.
3) The hospital’s discharge planner will follow-up by providing resources for potential placement in a nursing home or rehab facility. The patient and his or her family would need to explore and decide where the patient would be sent. Rehab facilities have their own separate rules for placement. For instance, if a patient needs acute rehab, that person needs to be able to participate in therapy 3 hours a day with a reasonable expectation of improving his or her physical or mental function. How long they’ll be able to stay there depends on how much progress they’re making. Also, with Skilled Nursing Facility placement, the number of days Medicare covers is limited. Again, the patient must need skilled care of some sort. Long-term placement in either of the previous kinds of facilities is not covered by Medicare, but MediCal does cover the costs if the patient is poor enough to qualify.
4) There isn’t much that a hospital can do if the patient insists on going home. Again, we see that fairly often. These people generally get readmitted to the hospitalized fairly quickly. All that can be done is to advise them regarding concerns about their safety. If they are a threat to themselves, they get referred to Adult Protective Services (APS). It just kind of flags them in the system. APS doesn’t have many resources either.
Thank you, Sis, for providing an overview of discharge planning. For family caregivers, the moment when a patient is discharged from the hospital may very well mark the end of an “acute” health care episode and the beginning of a long-term decline with many dips and valleys. Caregivers face a huge challenge in figuring out how to get the appropriate help for their loved one and in getting the loved one to accept that help.