My frail neighbor

Iris L.

I am writing regarding my 90 year old frail neighbor who does not have dementia.  She is a cardiac patient and is mostly homebound, she is also legally blind.  Last week she fell in the shower.  I told her to call her HMO and tell them that she needed home physical therapy for balance.  This would enable her to have a nurse make home visits and perhaps a social worker. Today a nurse called and told her that if she could not come in to the office, they had nothing for her.

I am upset.  I want to chastise them for not providing home care for her.  I know I should check her policy limits.  Today was the last day to make Medicare changes, although she loves her HMO insurance plan.  I am less than impressed. 

 She needs to be in assisted living or a board and care home.  This is what I am going to suggest to her.  I even believe she might be a hospice candidate, although I will not bring this up to her at this time.  She is in very bad shape.

She has no children.  Her weekly housekeeper has been coming every day since the fall.

I have offered to speak to her HMO on her behalf.   My question is how much care is common for an HMO to provide for the homebound?  

This is all I can write now.  I already know what should happen, but I don't have the means to get anything done.

Iris

M1

Iris she is very lucky to have you to help her. Maybe she would let you talk to her doc, who could order a home health assessment? Im more familiar with the Medicaid rules than Medicare, but it can't hurt to ask. I suspect you are right that she shouldn't be living alone.

Ed1937

Iris, you are a true gem. Thanks for looking out for her.

Iris L.

Thank you, M1 and Ed for responding.  She has requested a telehealth appointment with her doctor for the home health assessment and physical therapist.  We has a good talk and she is aware of her condition.  She actually is very strong and persistent when she is feeling well.  I offered to speak for her, but she wants to speak for herself.  I'll see what comes out of this.  She seemed better yesterday.  Thanks, again.

Iris

Jo C.

What a kind and caring person you are Iris; you are correct, something is really amiss.  She would have to let the HMO know that you are authorized to speak on her behalf and that information can be provided ala HIPAA law.  It may be that your neighbor is not providing sufficient information and perhaps did not have good or sufficient communications to explain her needs well and she does not know or understand the dynamics which puts her at a disadvantage.

If she can attend an appt. with her physician in a wheelchair, that is one thing; but if she cannot do so due to disability, severity of condition, or if it is a severe taxing effort, then help needs to come to her and indeed can be ordered as a medical necessity.

NOTE:  What I do know with certainty, is that all HMOs must provide all the same benefits that Medicare does for those who would qualify for regular Medicare.  That is mandated.  They can provide more, but they cannot provide less.

HMOs may provide all sorts of care without jumping through some of the Medicare hoops; such as, skilled care rehab for an HMO does not require the three day qualifying stay in an acute hospital; the HMO can choose to admit after less days in the acute hospital as well as admitting the patient to skilled care rehab instead of an acute med center at all IF the HMOs contract benefits do not state otherwise.  Most of them are willing to do that as it is far less expensive for them.

But I digress.  If she would permit you to assist her, it would be good to contact the Social Services Department of the HMO to get direction and some assistance.  The MD would need to order Home Health and the referral actually made.  If it is a small HMO, then there would be sparse Social Service staff usually easy to access.  If it is a very large HMO as is the one with its own hospital in Downey, (you know the one I mean), that is more difficult by far.  One can indeed contact the Social Services Dept.; also, that Downey HMO actually has a geriatric group for outpatient services not at the hospital that follows patients; it is a bit of a maze to get through.  If you have difficulty reaching someone at any HMO, then you can contact the Patient Services Department which that Downey HMO has a good sized department and state the case firmly being detailed about the needs.  Some of the smaller HMOs actually use their Utilization RN or Case Management RN to manage such dynamics.  It will be easy to find out, but ALL HMOs have Patient Services.

I had to do this sort of thing for my step SIL who had cancer; it was an HMO nightmare of epic proportions.  I finally got ahold of the Administrator of Patient Services and nicely but very firmly stated the detailed failings and patients medical needs and she cut through the red tape and got things going.

Your dear neighbor should have a Home Health RN assessment which probably would be one visit, that person would assess the need for P.T. in the home (hopefully.)  AND she should have a home visit by the HMO Social Worker to assess and outline a plan and resources.  If the Home Health RN feels that Hospice or Palliative Care is needed, she could refer your neighbor if your neighbor will accept it. If it is felt that a stay in a SNF or Skilled Care is necessary, the HMO can authorize that on a short term basis.  Such an authorized stay is not extremely long and if it needs to be protracted without actual medical necessity, then the patient becomes responsible for payment.

If you know of some acceptable care facilities near your area, then at least if she needed and accepted placement on a permanent basis, perhaps you could share with her the information you have.  Easy to look up facilities online and screen them.  If she wants to stay at home and she eventually has Hospice, it would be good to have the extra eyes, ears and oversight of the Hospice staff in regard to her care.

Some people actually continue to stay in their own home at the end of life and die at home while having only a paid carer and no family or S.O.s to assist them. If she is relying on paid caregivers only, it would be really a very good idea for someone to have a bit of oversight for her. It is necessary for such care aides to know that someone is looking out for the patient.  I have experienced some pretty negative things occurring when the patient is being cared for by an aide and no one is looking out for the quality of care as well as the actual appropriateness of care, aide behaviors, and ability to know when the patient has needs that are going unmet or worse; just do not care.. Hopefully your neighbor has adequate funds to carry her through her care needs.

It would be, if it is appropriate, a good thing to discuss her legal needs for a DPOA, and Advance Directives with her and see if she has them.  If she needs those documents, an attorney can go to the house; many of them do that.

I so hope that good help can be obtained; you are a very good hearted person and being a retired Physician, I imagine you feel the unmet needs strongly and are trying to be an advocate for her. She is blessed to have you as her neighbor.

Let us know how it is going, so hope she will have her needs met and will be provided good nurturing care.

J.

JJ401

Would she let you be present for (and talk at) the telehealth appointment? I’m thinking speaker phone.

Iris L.

Jo C. wrote:

 , then you can contact the Patient Services Department which that Downey HMO has a good sized department and state the case firmly being detailed about the needs.  

Jo C, I am sitting down trying to recuperate from my two hour telephone contact with the above mentioned large HMO, initially with the computerized phone tree, then finally with a person.  I took your advice and requested Patient Services, which they call Member Services.  I was with my neighbor and we spoke together via her speakerphone.  I identified myself as the neighbor and she gave her consent for me to speak on her behalf.

As you state, the jist of this is to be able to firmly state the needs and request and what lead up to this.  I was able to be firm and stick to the point.  My neighbor, although she does not have dementia, and in fact is usually quite sharp, is hard of hearing, not a native English speaker, and not feeling well now.  She has not been able to be diligent and persistent in dealing with being on hold and getting the run-around.

The Member Services representative took down the complaint and actually did contact the home medical office.  She already has a scheduled appt for 1/14/23, no earlier appointments are available.  The resolution is that my neighbor can call early in the morning to request a same day appointment.  I wish I had known about that ten days ago!

My neighbor is barely ambulatory with a walker.  Our complex is not suitable for walkers or wheelchairs, there are steps but no ramps.  I cannot handle if she were to fall.  Also, I have an SUV, I don't know if she can enter.  The HMO suggested an ambulance, which she doesn't want.  Nevertheless, someway, we will get her in.  She has a middle aged friend who is also helping her, we can work together.  Her housecleaner is now coming in daily to prepare her lunch and dinner.

It is very hard working with a neighbor.  I am not a relative, so I am reluctant to push too much.  But I feel like I have to push, because problems and crises will continue to arise.

Thank you for your detailed advice.  I will let you know what happens. 

Iris

Iris L.

My neighbor was feeling a bit better today.  Her close friend will call for a same day appointment on Monday, and she will be able to take her there.  She has family who can assist if necessary.  Once she sees a doctor, she can get medication and get enrolled into Home Health Care.  

JJ, I would have been willing to speak with her on a telehealth appointment call.  I wish the HMO would have offered a same day appointment last week.

Jo C, the three of us discussed assisted living, and she has agree that now is the time to begin to make arrangements.  We also discussed the legal documents.  She has some documents that need to be reviewed by an elder lawyer.

Iris

M1

You've gone above and beyond and you've obviously made a difference, Iris.  Again, she's very lucky to have you.

Jo C.

Dearest Iris; you have made a huge difference in the quality of this woman's life sticking to her significant needs despite the challenges involved.  You are a very caring person; your light shines very brightly.

It is good to hear that this person also has some people in her life; so hope they step up and make a difference.  That she is willing to go to Assisted Living should make a difference in that she will have so much more support and services and activity as she wishes.  Considering her circumstances, that should be a big plus.  

One of the most often looked into assisted living facilities in the area is, Sunrise in Seal Beach which also has a sister facility, Sunrise of La Palma.   My experience in the past has been that the La Palma facility is less expensive than the Seal Beach site.  Drawback is that they do Assisted Living only with no step down as a person ages into needing more care.  That is not a comforting thought.

There is a none-profit Assisted Living nearby in Stanton, Rowntree Gardens; they have Assisted Living as well as Memory Care and Nursing Home level of care.  Long ago, they used to be known as Quaker Gardens as they are owned by the Quakers. 

There are multiple others of course and sure can find them online; if she decides to accept a care facility that has step-down capability for different levels of care, she would probably be best served for both now and in the future.

May all goes well and smoothly with her physician appointment as well as with her finding a new place to move to; it will be your friendship and heartfelt caring that will make a big difference in this person's quality of life.  Well done Iris!

J.

Michael Ellenbogen

Great Job Iris. It sounds like you have this under controll but if you need an help let me know.

jfkoc

Thank you for the update and please continue to keep us in the loop

ladyzetta

Iris, She is so lucky to have you as her neighbor. Your very warm and caring. Hugs Zetta

Mint

Iris how kind of you.

Ed1937

Iris, that is great news. I hope others are as kind to you as you are to her. She is a lucky person to have you on her side. Thank you!!

Joydean

Iris you are definitely one of a kind. Most neighbors would have just looked the other way! Thank God you are there for her!

Iris L.

My neighbor was better today, she was up and walking about a bit.  We talked some more, she revealed that her close friend is her POA because she looks upon her like her daughter.  I reminded them both to inform her medical office and for her to sign the HIPPA form.  I made a short list of medical issues to be sure to cover with the doctor, and encouraged them to insist on home health care and physical therapy.  

I feel better knowing that things are being covered.  The friend never was a caregiver before, because her own mother is in good health,  and she admitted to feeling unsure.  I told her to call on me at any time because I have been through this with my own mother, also I have learned a lot from being around other older adults and of course from reading the experiences of members here.  

Jo C, the friend has a place picked out, but I will keep your recommendations in mind if the first choice doesn't work out.

Often people are told they may have to wait for a crisis to move things along.  I understand this, but this is a nerve-wracking way to live.  We are all fortunate that this crisis wasn't worse.  Helping her is a privilege,  because she and her husband had helped me over the years, in fact, we helped each other, as good neighbors do.

Iris

Jo C.

What a wonderful resource you are, your input and the assistance you are providing is priceless for the neighbor's benefit.

As for the ALFs I mentioned; I am definitely not recommending them - the two Sunsets I mentioned are simply two that so many people look at; but I did read the many Yelp reviews and they were not at all a positive from far too many.

Can you mention the ALF your neighbor has chosen?  So much has changed; not just due to COVID, but for many reasons.  My favorite place for quality of care is in Artesia and owned by Dutch churches, but the are plain wrap; not at all fancy and the rooms are smaller.

There is one in Cerritos looks like a fancy hotel lobby and some of the apartments are larger; especially the two bedrooms with each bedroom having its own good sized en suite bathroom and each having its own walk-in closet. Living room and small kitchenette adjoining the living room.  Lots of space with library, computer room, screening movie room, etc. and will say; great outdoor spaces, but the cost of care and added costs as things change is pretty high.  Have no idea what their care and staffing is like.  Many residents are completely independent and strong.  Actual care and staffing is always the big unknown which is really extremely important and of course staffing is where cuts are often made by owners and also by admin folks who often get bonuses predicated on  their budget capabilities to hold costs low as possible; same as acute med centers.

So . . . when a good facility is found, it is like gold.  Hope your neighbor does well and that she is happy with her decision.

J.

Iris L.

Jo C, it is the friend who has chosen the assisted living facility, one that is close to where she lives.  I will ask her for the name.

The friend got up early this morning to begin calling for a same day appointment, and was successful.  She also requested time off from her job.  But my neighbor changed her mind, and decided she was not going out because it was too cold.  Fortunately, the friend was insistent and they did make the appointment.  She did not see her regular doctor, but she saw the on-call doctor.  Medication was prescribed.

Tomorrow there will be an appointment with a home health nurse.  Things are moving along.

People are saying I am nice, but I am doing only a little.  I got frustrated when she said she wasn't going, after all the anxiety and work we had put in for her.  The friend is really the one who is nice, driving to visit her every day and driving her to the doctor and driving to get her medication from the pharmacy far away in another city, and leaving her job on short notice.  People don't appreciate the efforts that other people do for them. 

Iris

Iris L.

I waited for one hour with my neighbor for the appointment that she said she had.  No one came or called.  She gave me the woman's telephone number and I left a message, but I could not make out who this woman was.  I asked her yo refer all calls to me or to her friend in the future.  She cannot hear well enough to talk with strangers on the telephone.

Iris

Iris L.

Question: how ambulatory must an elder be for admittance to assisted living?

My neighbor spends 23 hours in bed.  She can walk to the bathroom and to the dining table to eat, using the walker, otherwise she is in bed.  She has a hard time getting up from the bed.  She is a cardiac patient, no dementia.

Iris

Jo C.

This is a question with variable answers.  It will depend upon the facility and willingness and capabilities of the ALF as to how much independence a person must have to qualify for admission as ALFs are not licensed or staffed as NHs are.  ALFs have licensing requirements to adhere to.  Some ALFs are more accommodating than others.  NOTE:  Most ALFs do meet with and screen potential residents, sometimes even in their home setting prior to approving them for admission to ensure the potential resident meets their criteria/standards for admission.

The person being admitted to an ALF must be able to have a degree of capability of being able to be somewhat mobile, or in some, be able to transfer to a wheelchair including perhaps a motorized wheelchair.  However, in the greater number of ALFs, wheelchairs are not a plus and sometimes not accepted.  One needs to be able to get to the dining room for all meals as said meals are not brought to the room unless a person has a short term need of a few days of being ill; most often up to three days. 

Some ALFs are a model where a person must be completely ambulatory; other ALFs may permit a person being wheelchair bound and need no more than one aide assistance for transfers from bed to chair and back.  If the person can stand, pivot and transfer that is often a measurement for those facilities willing to take the more compromised persons - the ability to stand/pivot/transfer is often an absolute necessity.  Ability to manage their own toileting or their own changing of incontinence supplies can be a criteria for ALFs; they are not NH licensed.  Bedside commodes are not acceptable.  Licensing is important and sets the overall standard of care that can be provided.

Does your neighbor have an electric scooter or electric wheelchair that she is able to get around in?  Getting to meals and activities independently are an issue for some ALFs, one would have to screen facilities for that.  There may be some ALFs that would be willing to have an aide wheel a resident to meals and activities, but that is not the norm.

NOTE:  Considering your neighbors situation and needs, I would strongly recommend that her friend be spoken with regarding the reality of ALF requirements for residents, and then she should check details with the facility she is thinking of for your neighbor.  It would also be an idea to go to the Rountree Gardens to see and screen that setting and what they have to offer as a possible backup plan. They have multiple stepdown settings and are known for their care. HOWEVER: I have not been out there to see the facility myself.  It is large on expanded grounds with gardens and has independent living, assisted living, nursing home level, and memory care.  They do a good job according to reviews as well as one family I knew who had their LOs there.  They had an RN who assisted one of them several times a day in their own apartment who had a chronic condtion requiring changes of dressings for quite some time. It was not Home Health, it was a facility RN. They also have multiple physicians who come routinely to the facility and have actual exam rooms for appointments for all levels of care.

Your friend; would she be able to go to the dining room for all meals?  Would she want to go to activities?  She will need to pay extra for medication assistance, shower assistance, transfer assistance and wheelchair assistance.  There will be "Level of Care" packages for extra cost to provide extra care items that the facility is willing to accommodate.

Since your neighbor has no behavioral problems and does not have dementia, that will be a significant plus for ALFs.  You can use Google to look up ALF criteria for residents.

The need has not reached crisis at this point, so there is a bit of time to make certain all the ducks are in a row as best as can be for your neighbor and additional screening of ALFs may be good for a "just in case" sort of backup.  It may well be once she is in care that your neighbor will do better than she has done at home. Wouldn't that be wonderful!

J.

Iris L.

Jo C, thank you for your extensive reply.  My neighbor had fallen about two years ago, since then, she has been ambulatory outside by leaning on someone's arm.  Up until now, she had resisted using a walker, but now she must.

She slipped and fell in the bathtub because she did not have a rubber shower mat.  She said she did not know she was supposed to use one.  I had a talk with her about making changes and preparations as we get older, we can't avoid these changes.  

I doubt very much that she could learn to use a motorized wheelchair or scooter--she never drove, due to poor eyesight, and she has no spatial awareness.

I even have doubts about her getting to a dining room on her own, I know she would feel more comfortable if someone were to accompany her.  Also, I don't know if she has the strength to walk two or three times a day to a dining room.

So far, she manages okay with her own toileting.

I don't know if I mentioned that she is legally blind due to macular degeneration.  She can see and read, but not too much.   

I am familiar with Rountree Gardens from radio commercials and ads.  I am considering it for myself, in time.  My neighbor's friend had chosen an assisted living facility very close to her home, about a year or so ago.  So much has changed,  including the severe staffing shortages due to multiple social factors.  Right now my neighbor has her cleaner come by every day, to prepare her food and assist as needed, but she won't get that personal attention in assisted living.

Right now, I am awaiting home physical therapy for her.  She has to become more ambulatory.  We'll see if this is possible.

It is already another weekend.  She fell almost three weeks ago, and no home services have been set up by her medical plan, you know the one I am referring to.  I am going to get on the telephone again and see what's going on.

Iris

Iris L.

Today I observed that the tea kettle was dry and one of the stove burners was still lit.  I let her know, and she said she must have forgotten.  Also, her close friend has observed that she has left the faucet running. This absentmindedness is not dementia, but it certainly bears watching.  She will soon be 91, so some forgetfulness is not surprising. 

Iris

Addendum: I called my neighbor to tell her I was coming over to check on her and she got mad because I had spoken to her friend and to her cleaner about the lit stove.  She said I was treating her like a person not in her right mind.  She said she usually dries the tea kettle out by placing it over the flame for about five minutes.  She forgot that she had told me earlier that she had forgotten.  I told her that wasn't safe, she said she would pay better attention.  We talked about an electric kettle that would turn off automatically, she doesn't want one. She agreed to stay in the kitchen until the kettle was dry.  

I'm not happy with this.  I know how easy it is to walk away and forget the stove, because I have done it.  I solved my problem by not using the stove.

On another note, the physical therapist will come tomorrow.

Iris

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Iris L.

You make some good points, Victoria.  Three years ago, at the beginning of the Covid pandemic, she asked me to sit with her as she enrolled her very ill husband into hospice.  I have been close by ever since.  In fact, the other two ladies began to work closely with her only after her husband passed away.  

I don't think our friendship will be in danger.  But you are right, she has chosen those two ladies to be most involved in her care.  I need to let them handle things for her.  But I can't turn my back if I see a need.

Iris

eaglemom

Iris, I wanted to check on you and your frail neighbor. You've been a very good friend to her. I wouldn't be able to sit back and do nothing either.

My concern is that its too much for you. Just checking on you.

eagle

Iris L.

Hello, Eagle Mom, I am doing okay.  Actually, my neighbor is doing better, three weeks after a big fall, despite limited involvement from her health plan.  I feel like I have to say something because I know what should be done.  Before her big fall she was ambulatory without the walker.  I hope she can get back to that level.  Even seniors without dementia need close attention, because they may be frail and weak from cardiac issues. 

Iris

Iris L.

UPDATE

I am posting this update as a caution to others who are caring for or in contact with a frail elder who does not have dementia.  My neighbor had been on a diuretic, but recently stopped on her own because she decided she no longer needed it.  But then she began feeling worse.  She told me that the prescribed 1/2 pill did nothing for her, so she decided to take a whole pill every other day.  I told her that didn't make sense.  She has a doctor's appointment in two days, and I told her and her caregiver who will accompany her to be sure to bring this up with the doctor.  

I am posting this as a caution because often family caregivers will report that their non-dementia parent or grandparent is doing great. But one never knows without questioning them carefully.  Especially in regards to medications, if they decide to make changes on their own.  Be careful not to take everything they tell you as gospel, because they may not comprehend the consequences of their action.  We have to question them, because they will not bring this up on their own.

  

Victoria, I did remove my name from her Life Alert notification.