Increasing Trips to ER

Wilted Daughter

90 yr old mom fainted yesterday and taken to ER. Fainting/ER incidents are increasing and frightening to me when they occur. Mom tells me she has no recall of what happened after she  but tell stories when asked questions, PCP mentioned test results show low blood pressure etc.

The main issues, causes for concern are increasing high glucose levels (after medicine adjustment), low blood pressure (medicines or ?), increasing limited mobility, and VD.

The hospital transferred mom from ER to room yesterday, and I want her to stay for a few days with a care plan that addresses stabilization of glucose levels, medicine review/adjustment if needed, evaluate cause(s) for low blood pressure/frequent fainting. Are these reasonable requests...I don't want to be unreasonable but need a complete evaluation before discharge. This is very stressful to see mom stretched out on the floor, eye wide open and not knowing when it will happen next. 

SusanB-dil

Don't know about staying days, but just my little opinion, it seems to me those issues should all be more stable before they release her.  So no, I don't see where you are being unreasonable. If anything, that makes sense, rather than have her fainting and possibly getting hurt upon falling. The high-glucose issue isn't so good, either - maybe they can figure what's causing it.

MN Chickadee

You might want to ask whether she has actually been admitted. Sometimes hospitals keep someone for "observation" and then medicare will not pay for it. The issues/goals you are describing sound ripe for that, so I would inquire about that status before asking them to keep her longer. Some of our folks here from the medical field may be able to comment on the chances of them being able to troubleshoot those issues in the hospital. 

Have you witnessed the fainting? Any chance it is seizures? My mother had no history of seizures and then got them in late stage Alzheimers.  

When she gets home you might consider a hospice evaluation. It sounds like her medication needs are complex and not working at the moment. Hospice may be able to help figure out the best way to make her safe and comfortable and avoid ER visits. 

easy23

MN Chickadee wrote:

You might want to ask whether she has actually been admitted. Sometimes hospitals keep someone for "observation" and then medicare will not pay for it. The issues/goals you are describing sound ripe for that, so I would inquire about that status before asking them to keep her longer. Some of our folks here from the medical field may be able to comment on the chances of them being able to troubleshoot those issues in the hospital. 

Have you witnessed the fainting? Any chance it is seizures? My mother had no history of seizures and then got them in late stage Alzheimers.  

When she gets home you might consider a hospice evaluation. It sounds like her medication needs are complex and not working at the moment. Hospice may be able to help figure out the best way to make her safe and comfortable and avoid ER visits. 

                                                                                                                                                                             

Medicare paid for my husband's hospitalizations when he was under "observation" status.

MN Chickadee

                    

Medicare paid for my husband's hospitalizations when he was under "observation" status.

Under observation status Medicare Part A won’t pay for it, it would fall under Medicare Part B, and could mean you owe a large co-pay; 20% of a hospital stay adds up fast. It also can depend on whether you are in a Medicare Advantage plan or if you buy a supplement plan. Definitely worth asking about this if finances are a concern because the observation versus admitted status can mean a lot of money out of your pocket and often comes as a surprise to people.  

easy23

MN Chickadee wrote:

                    

Medicare paid for my husband's hospitalizations when he was under "observation" status.

Under observation status Medicare Part A won’t pay for it, it would fall under Medicare Part B, and could mean you owe a large co-pay; 20% of a hospital stay adds up fast. It also can depend on whether you are in a Medicare Advantage plan or if you buy a supplement plan. Definitely worth asking about this if finances are a concern because the observation versus admitted status can mean a lot of money out of your pocket and often comes as a surprise to people.  

 Each time my husband was placed in observation status he was given a

Medicare Outpatient Observation Notice (MOON).  There should be no surprises!

sandwichone123

Your mom is 90 years old. At some point you will want to decide whether to continue running her to the ER for things that keep happening. You might consider bringing hospice on board, as they can be very helpful with preventing such incidents rather than coping with them afterward (although they're helpful with that too).

mommyandme (m&m)

My mother’s syncope episodes went from one a week to a couple a day.  She actually had one during her doctor appointment. That was good as it helped the doc see what I was talking about.   They were not from getting up too quickly.  She then had an echocardiogram, but her heart was fine.  We did get an oxygen concentrator in the house which would help bring her back enough to get her off the floor or wherever.  She too would have her eyes slightly open and would run at the nose and mouth.  Fortunately she already had 24/7 care so she was always helped to the floor or wherever.  Nevertheless, these episodes are what prompted my contacting hospice. She doesn’t faint anymore because she never leaves her bed. Bittersweet.

Jo C.

This is a bit long, but there is much information to be shared which most persons having Medicare for themselve or their LOs are unaware and it is very important:

Hello Wilted, you are certainly taking the right track on this.  I do wonder if they have admitted your mother to a unit that has cardiac monitoring so they can track her heart rhythm in an ongoing manner; that and all the other points you have raised would lead to an accurate diagnosis and appropriate treatment which more than likely would be oral meds or at most, a pacemaker.  Falling is best to be prevented.  As we know; fractures can add another set of huge issues to already existing problems.

As for the admission.  It is a very unfortunate set of dynamics, but the Medicare rules changed some time ago, and hospitals are now permitted to admit a patient as an Outpatient, rather than an Inpatient even when staying multiple days AND the hospital can indeed change the patient to an Outpatient status even if they were initially admitted as an Inpatient.  This is true for all "Original Medicare" patients; if you have Medicare Advantage coverage, then you would need to contact your plan to find out what their rules are as Advantage programs have different benefits and each Advantage Program can differ from another Advantage program, you will want to know your own specifics.

A letter is supposed to be given to the patient or family member when made an Outpatient, BUT this has had some failures for a variety of reasons.   Sometimes, the letter was given to a patient not capable of understanding and the letter misplaced in a drawer; sometimes the letter was misgiven; sometimes the person receiving the letter simply did not understand full ramifications.  A myriad of reasons why the information may have been missed including occasionally, the failure of a letter to be delivered.

NOTE:  Is is extremely important to ask at the time of admission, that yourself or a LO be admitted as an inpatient, and even the, "Medicare and You," book states that a Medicare insured  Inpatient should check EACH DAY the person is in the hospital to ensure that the hospitalized person is continuing as an Inpatient. 

WHY:  When admitted as an Outpatient, services are paid ONLY for PART B Outpatient services; lab, x-ray, P.T., physician visit, etc.  What is NOT paid, is Part A which covers the cost of each day for the room and all non-Part B services. That hefty fee per day comes out of the patient's own pocket while also having to pay for any deductibles and co-pays which may apply.   If one has a Medigap Supplement Policy, one would want to contact the supplement plan to find out how they cover for inhospital outpatient status, especially when the stay is for multiple days.  Supplement Plans can widely differ from one another.

IMPORTANT:  When a person is going to need Skilled Care, (rehab), following an acute hospital stay, there is an absolute requirement that the patient MUST have been on an Inpatient Status in an acute care hospital for THREE full days.  That is dyed in the wool; no exceptions whatsoever.  If one's entire hospitalization over multiple days was outpatient; there is NO rehab coverage by Medicare.  If one was an Outpatient for one day and then had two Inpatient Days; there is NO rehab.  Again, Advantage programs often differ, contact your Advantage Plan to find out the benefit coverage.

One MUST have those three 24 hour days as an Inpatient in an acute med center in order to receive Skilled Care Rehab Medicare Coverage with Original Medicare.

We did indeed have a Member here who related that her LO was kept as a Medicare Outpatient for ten days.  Her LO was then transferred to a Skilled Care Rehab. Somehow, the fact that the hospital stay was all outpatient was missed by the Rehab and the ramifications not known by the Member.  Anyway; the LO was not covered for Rehab, therefore, Medicare denied coverage and the patient owed the entire amount for the entire stay at the Rehab; it was in the thousands.  Dreadful situation.

It used to be that there was a 24 Hour Outpatient status in the acute hospital to assess for medical necessity for Inpatient Admission for some patients; that worked well.  However, the hospital is benefitted in several ways by having Medicare patients remain as an Outpatient for all hospital days and that got changed to what we are now facing which is causing much difficulty.

So . . . always at the time of admission and then check each and every day during admission to ascertain the Inpatent versus Outpatient status.

NOTE:  If your Primary Care Physician follows you or your LO in the hospital, your chances of a good outcome requesting Inpatient status and staying that way regarding this dynamic are much better; HOWEVER; many patients when admitted to the hospital are now followed by a "Hospitalist" physician, not their own Primary MD.  This has created more issues and it has become far more popular with the new hula hoop of, "Value Based Medicine," which has sprung up like toxic mushrooms all over the U.S.  It really helps to keep the costs down for the providers of care - especially the acute med hospital centers AND the MDs in these Value Based Plans receive financial incentives for holding down costs including bonsuses which are given a different name, and the same MDs will receive "penalties" if their costs of care are higher. This is a system fraught with issues as we can imagine. Some of the Value Based Groups insist that the enrolled patients who often do not understand they are enrolled in such a group cannot even access doctor's office appointments without going through a non-physician party first. Delays in care with primarys and specialists and other care have been some of the issues highly criticized.

Really good to stay informed so we know how to hold our own if it becomes necessary. 

J.

Jo C.

This is a bit long, but there is much information to be shared which most persons having Medicare for themselve or their LOs are unaware and it is very important:

Hello Wilted, you are certainly taking the right track on this.  I do wonder if they have admitted your mother to a unit that has cardiac monitoring so they can track her heart rhythm in an ongoing manner; that and all the other points you have raised would lead to an accurate diagnosis and appropriate treatment which more than likely be oral meds or at most, a pacemaker.  Falling is best to be prevented as we know; fractures can add another set of huge issues to already existing problems.

As for the admission.  It is a very unfortunate dynamics, but the Medicare rules changed some time ago, and hospitals are now permitted to admit a patient as an Outpatient, rather than an Inpatient even when staying multiple days AND the hospital can indeed change the patient to an Outpatient status even if they were initially admitted as an Inpatient.  This is true for all Original Medicare patients; if you have Medicare Advantage coverage, then you would need to contact your plan to find out what their rules are as Advantage programs have different benefits and each Advantage Program can differ from another Advantage program, you will want to know your own specifics.

A letter is supposed to be given to the patient or family member when made an Outpatient, BUT this has had some failures for a variety of reasons.   Sometimes, the letter got given to a patient not capable of understanding and the letter misplaced in a drawer; sometimes the letter was misgiven; sometimes the person receiving the letter simply did not understand full ramifications.  A myriad of reasons why the information may have been missed including occasionally, the failure of a letter to be delivered.

NOTE:  Is is extremely important to ask at the time of admission, that yourself or a LO be admitted as an inpatient, and even the, "Medicare and You," book states that a Medicare insured  Inpatient should check EACH DAY the person is in the hospital to ensure that the hospitalized person is continuing as an Inpatient. 

WHY:  When admitted as an Outpatient, services are paid ONLY for PART B Outpatient services; lab, x-ray, P.T., physician visit, etc.  What is NOT paid, is Part A which covers the cost of each day for the room and all non-Part B services. That hefty fee per day comes out of the patient's own pocket while also having to pay for any deductibles and co-pays which may apply.   If one has a Medigap Supplement Policy, one would want to contact the supplement plan to find out how they cover for inhospital outpatient status, especially when the stay is for multiple days.

IMPORTANT:   When a person is going to need Skilled Care, (rehab), following an acute hospital stay, there is an absolute requirement that the patient MUST have been on an Inpatient Status in an acute care hospital for THREE full days.  That is dyed in the wool; no exceptions whatsoever.  If one's entire hospitalization over multiple days was outpatient; there is NO rehab.  If one was an Outpatient for one day and then had two Inpatient Days; there is NO rehab.

One MUST have those three 24 hour days as an Inpatient in an acute med center in order to receive Skilled Care Rehab.

We did indeed have a Member here who related that her LO was kept as a Medicare Outpatient for ten days.  Her LO was then transferred to a Skilled Care Rehab. Somehow, the fact that the hospital stay was all outpatient was missed by the Rehab and the ramifications not known by the Member.  Anyway; the LO was not covered for Rehab, therefor Medicare denied coverage and the patient owed the entire amount for the entire stay at the Rehab; it was in the thousands.  Dreadful situation.

It used to be that there was a 24 Hour Outpatient status in the acute hospital to assess for medical necessity for Inpatient Admission for some patients; that worked well.  However, the hospital is benefitted in several ways by having Medicare patients remain as an Outpatient for all hospital days and that got changed to what we are now facing which is causing much difficulty.

So . . . always at the time of admission and then check each and every day during admission to ascertain the Inpatent versus Outpatient status.

NOTE:  If your Primary Care Physician follows you or your LO in the hospital, your chances of a good outcome requesting Inpatient status and staying that way regarding this dynamic are much better; HOWEVER; many patients when admitted to the hospital are now followed by a "Hospitalist" physician, not their own Primary MD.  This created more issues and it is becoming more popular with the new hula hoop of, "Value Based Medicine" which has sprung up like toxic mushrooms all over the U.S.  It really helps to keep the costs down for the providers of care - especially the acute med hospital centers AND the MDs in these plans receive financial incentives for holding down costs including bonsuses which are given a different name, and the same MDs will receive a "penalty" if their costs of care are higher. This is a system fraught with issues as we can imagine. Some of the Value Based Groups insist that the enrolled patients who often do not understand they are enrolled in such a group cannot even access doctor's office appointments without going through a non-physician party first. Delays in care with primarys and specialists and other care have been some of the issues highly criticized.

Really good to stay informed so we know how to hold our own if it becomes necessary. 

J.

Jo C.

ttt

Wilted Daughter

Thank you all for your responses. Mom stayed in the hospital as an 'outpatient' for (3) days. Her PCP sought pre-approval from Medicare Advantage plan while she was in the ER. She has secondary insurance so billing is not the concern. 

Currently she's in SNF, rehab and scheduled to come home on Tuesday (7days rehab). When she arrives home, I will request hospice evaluation as this is an ongoing issue for many years (diabetes, low blood pressure, medicines...)?  All her meds list side effects (dizziness, fainting...) and her blood sugar level was 400+ for 3 days. The hospital tested A1C 10+ She tests herself, but now I have to manage, which I think should change to a monitoring device as shown on TV. We need new methods all around for controlling blood sugar/blood pressure and more eyes on the ball. 

I informed her PCP in spring about issues with med mgmt., elevated A1C and testing daily blood sugars, with a request to admit her for observation. No action was taken then. After every fall dementia worsens, along with overall decline. She does not recover to pre-fall condition. This can't continue...

Quilting brings calm

Wilted- 

My spouse is a type 2 diabetic and is on a continuous glucose monitor.  He tried the Free Libre but didn’t  like it.  It kept falling off the back of his  arm and he also had to hold his phone up next  to it to get a reading.  He now uses the Dexcom 6.  It goes on his stomach, gives automatic readings and notifications, sensor gets replaced every 10 days ( transmitter good for 90 days), and only  had 1 fall off  in a couple years.  It’s really helped him keep his glucose numbers down. 

The bad news?  Medicare will  only pay for it  if you use insulin 3 times or more a day.  He only uses  a long acting insulin pen once a day, so we are spending  $400 a month using good rx.  A transmitter will cost $200-300 more.  That’s an estimate as he hasn’t  had to buy a transmitter yet since he went on Medicare.  Some Advantage and private insurance  plans will cover it without the insulin requirement.