Geriatric psych hosp direct to SNF longterm care...

Ci2Ci

After 15 months of 24/7 care in my home, LO has been in geriatric psychiatric hospital/section for 4 weeks because of altered mental status, via ER. (She suddenly started becoming agitated, beligerent, and exit seeking. Imposter syndrome. Completely separated from reality; not even aware of the type of place she is in -- home or hospital. A sudden, dramatic drop from her baseline. Est. stage = moderate dementia)

I'm calling it delerium. Hospital insisting they've ruled that or any other medical issue out.

Before hospital, her BP was consistently ~123/68, managed by 2 BP meds daily and a super healthy diet. (In June, PCP reduced her BP meds, to bring >110.) Since in hospital, her BP has been out of control -- 200/## several times, and 99% of the time well over 140. They even added a 3rd BP med and still can't control it; now removed that added one because of side effects.  Psychiatry dismissing it as "typical elderly BP" or other excuse. (Not her typical by any stretch.)

She has had 1 fall since being in Ger. Psych.

QUESTION: They are about to discharge for institutional placement but not referring to short-term rehab. Discharging her as "neurodegenerative disorder with behavior disturbances". (She will have to apply for Medicaid-LTC on Day 1 at SNF.) She has never been in facility care before.

Anyone been in this boat? Direct from hospital to longterm care (secured unit)? Having to apply for Medicaid immediately.

ElCy

I thought my D H was early on in this disease. Two months ago he became extremely delusional and would not let me in the house for three days as he thought I was a stranger. 911 call resulted in 4 weeks in geripsych. Meds finally stabilized but I was told he could no longer be alone. I placed him in memory care and so far he is doing very well. We are not at Medicaid yet as he has 1 year of long term care insurance.

LaurenB

Short answers:

Delirium usually has a specific event or cause.  You've stated that your loved one doesn't have a new diagnosis to base the delirium on and I'm assuming that this is why your LO is just being diagnosed with their dementia.

As for the high blood pressure, I'm thinking that you may have been doing an amazing job of monitoring their diet.  Sadly, this is not the case with institutional foods.  Most of my clients that came to us with high blood pressure received a "No Added Salt" diet.  The only difference in their trays vs the food that others got, was no packet of salt or access to a salt shaker.  

Bypassing short term rehab...this could be for multiple reasons.  Can your loved one tolerate a certain number of hours of rehab per day?  Do they have a new diagnosis to use to bill for medicare when a PT/OT/SLP works with them?  Going to straight to long term care guarantees them a room at that facility.  Many of my nursing homes and skilled nursing facilities have two sections.  One for long term residents and one for short term.  You can't stay with us in the short term care more than 100 days (assuming that you are continuing to make progress).  Once that is up, you have to find a new place to live.  There often times in not an available bed in the other part of our facility to go to and the family ends up having to take the person home with them until a bed becomes available at a new facility.  By getting into a long term bed from day one and applying for medicaid, the facility knows what to expect and has a spot for your loved one.  Also, just because someone is in a long term bed does not mean that therapy can't work with them.  I've treated MANY direct to long term care residents.  Their progress is usually small and lasts a week or two, but we strive to get them to be at their current best ability.

Is the facility that your LO is going to really a secured unit?  These beds are hard to come by.  With a diagnosis of neurodegenerative disorder with behavioral disturbances" it means (and im sure you know this) that the disease is neurologic and will continue to degenerate as well as stating that they have more behavioral needs and will need more specialized housing.  We have worked with persons with dementia for 21+ years at my facilities and when someone has a diagnosis of behavioral disturbances, often the staff isn't equipped to best handle them.  These people that i'm familiar with have gone back and forth to the er and end up needing different medications.  If you can find a home that can help you loved on and manage them from the facility vs er I'd strongly consider it.

Sorry for the lengthy response.  I wish you all of the best in your journey.  

JJ401

My sister-in-law went directly from a geriatric psyc unit to a secured memory care unit. It was the correct placement. The activities of the memory care were geared to her needs. She would not have been as content in a regular nursing home (staying home was not an option at this point).

The facility included a nursing home and a rehab. Sister-in-law was taken to the rehab for about a month after she first arrived. When they determined she was not making progress, it was stopped.

toolbeltexpert

Ci2ci my dw went to the er via ambulance, then 12 hrs later to a geripsych, I had ask for that and insisted she wouldn't be safe at home and neither would I, then 6 weeks later to a snf, because that was the only place that had an open bed and took Medicaid, I had seen a cela and applied for Medicaid well after alot of filing legal documents and being denied because we needed to spend down part of my Ira, I decided that for us I would rather sell our house now and use the proceeds to first buy a small place and use the rest to fund dw care. So a bed opened at at mcf which does have a snf part that takes Medicaid, the cost of the mcf is 3659 at the lowest level,she is still at that level today, the snf she came from was 8750 for a 31 day month.

Each of us makes our own decisions based on our level of comfort and also the level of care we expect for our lo. I am thrilled where my dw is.

I can always go back to a Medicaid situation some day if things don't work out. We make our plans for our lo's but can't control the future so it may change?

Stewart 

Ci2Ci

Thank you all for the thoughtful replies.  Seems that direct to LTC route is best, if only for securing a bed.  

I hate her having to be on antipsychotics -- so scary. But, if this is the only way for her to be placed in a facility (best for her needs), what is the choice. It has seemed to help with the agitation; it has not helped with the delusions. I hope that the SNF can dial back what she is on. Geri-psych put her on scheduled Olanzapine (AM & PM) AND donepezil + namenda, all at the same time!  That really upsets me, for several reasons. It is condeming her to all those meds, since you can't tell which is or isn't working. Not sure any other doctor and/or SNF is going to take the time to sort all that out.  IMO, the dementia drugs should have been considered later, if at all.  I was not informed beforehand of their administration to refuse. 

Ci2Ci

ElCy wrote:

I thought my D H was early on in this disease. Two months ago he became extremely delusional and would not let me in the house for three days as he thought I was a stranger. 911 call resulted in 4 weeks in geripsych. Meds finally stabilized but I was told he could no longer be alone. I placed him in memory care and so far he is doing very well. We are not at Medicaid yet as he has 1 year of long term care insurance.

Same story for me. I wasn't locked out of house, but the stranger-danger started Oct. 4, just suddenly. The other dramatic change is that she has no awareness of her surroundings, based on context. She is in a geri-psych unit but has thought it was a school, a hotel, a convention center, Disney. This is why she's exit seeking -- she thinks that she's in a temporary place that she needs to check out of. 

So, more than just the occassional delusion anecdotes from before. Permanent disorientation. Poor dear.

Ci2Ci

LaurenB wrote:

As for the high blood pressure, I'm thinking that you may have been doing an amazing job of monitoring their diet.  Sadly, this is not the case with institutional foods.  Most of my clients that came to us with high blood pressure received a "No Added Salt" diet.  The only difference in their trays vs the food that others got, was no packet of salt or access to a salt shaker.  

Ironically, even though her BP is very out of control, the geri-psych wouldn't put her on a low sodium diet b/c she doesn't have a heart condition. Geez. Low-hanging fruit -- even if they don't try very hard at low-sodium.

Well, yes, she was on a very good diet (plantbased, low sodium, made-from-scratch). Her labs are amazing, even for a 30 year old, let alone an 87 year old. Lipid panel no longer out of range.  Her eGFR value went from 35 to 62, since in my care in just 15 months. (Improving kidney function not really suppose to be possible.)  Too bad a vegan diet can't fix the brain. 

Ci2Ci

LaurenB wrote:

Is the facility that your LO is going to really a secured unit?  These beds are hard to come by.  With a diagnosis of neurodegenerative disorder with behavioral disturbances" it means (and im sure you know this) that the disease is neurologic and will continue to degenerate as well as stating that they have more behavioral needs and will need more specialized housing.  

I've called dozens and dozens of SNFs, in Florida. The few that have secured units say their beds rarely come available. I've found one that not only has secured unit (and uses Wanderguard for added protection), but availability. And, it would be a great fit for LO, as it is a faith-based facility.  When describing my LOs behavioral issues (in the "I need to go home" phase), the admissions coordinator didn't feel LO would be a problem.  I'm crossing my fingers so hard that SNF will accept her. Stupid holidays delaying everything. 

Ci2Ci

toolbeltexpert wrote:

So a bed opened at at mcf which does have a snf part that takes Medicaid, the cost of the mcf is 3659 at the lowest level,she is still at that level today, the snf she came from was 8750 for a 31 day month.

Wow! That is cheap! That is a MC at SNF, not AL, right? I'd love to find something that cheap -- LO could private pay a wee bit to get the Medicaid ball rolling.  (Is that in the state noted in your profile?)

LaurenB

Ci2Ci wrote:

toolbeltexpert wrote:

So a bed opened at at mcf which does have a snf part that takes Medicaid, the cost of the mcf is 3659 at the lowest level,she is still at that level today, the snf she came from was 8750 for a 31 day month.

Wow! That is cheap! That is a MC at SNF, not AL, right? I'd love to find something that cheap -- LO could private pay a wee bit to get the Medicaid ball rolling.  (Is that in the state noted in your profile?)

I'm wondering about the difference in the prices.  At the SNF level of care there has to be a certain number of RNs and LPNs as well as CNAs per resident to be in compliance.  I imagine that costs a lot.  At the MC are they staffed with RNs or LPNs?  Are the daily caregivers CNAs?

Jo C.

C; before your mother discharges to a care facility, would her psychiatrist be willing to write an order for her primary medical doctor or other internal medicine physician to see her regarding her blood pressure.  

I would question that the significant increase in BP is not so much from not having a low sodium diet so much as it may be an effect from one of her new meds or the combination of the new meds.

Basically, if she can be seen and any sort of an adjustment done  in any way, that would be good.  Having her seen by a good primary care type physician prior to transfer would be easier than trying to arrange such after transfer.  Some SNF MDs are not always the ones we would want for the problem presenting especially if onset is prior to admission.    

As for Medicare giving 100 days of rehab care; that is as rare as hen's teeth in most situations AND one must fit Medicare Criteria for diagnosis and medical necessity for admission  for skilled care rehab in addition to the three 24 hour inpatient days in an acute hospital.  The average rehab length of stay according to Medicare is 12.4 days; this is for joint replacement, stroke, etc.  Where we are, the length of stay is usually two weeks to three weeks depending on patient's medical necessity with diagnosis and abilities in rehab.

Some skilled care rehabs are a little more lenient with admissions as long as basic diagnostic and medical need criteria for Medicare reimbursement is met.

My LO went from GeriPsych to long term care with no problems which actually surprised me as I thought there would be a lot of upset, but it went smoothly; I so hope that your LOs course of care will be a good one and a calm one.

Let us know how it goes,

J.

Ci2Ci

Jo C. wrote:

C; before your mother discharges to a care facility, would her psychiatrist be willing to write an order for her primary medical doctor or other internal medicine physician to see her regarding her blood pressure.  

I would question that the significant increase in BP is not so much from not having a low sodium diet so much as it may be an effect from one of her new meds or the combination of the new meds.

Basically, if she can be seen and any sort of an adjustment done  in any way, that would be good.  Having her seen by a good primary care type physician prior to transfer would be easier than trying to arrange such after transfer.  Some SNF MDs are not always the ones we would want for the problem presenting especially if onset is prior to admission.    

As for Medicare giving 100 days of rehab care; that is as rare as hen's teeth in most situations AND one must fit Medicare Criteria for diagnosis and medical necessity for admission  for skilled care rehab in addition to the three 24 hour inpatient days in an acute hospital.  The average rehab length of stay according to Medicare is 12.4 days; this is for joint replacement, stroke, etc.  Where we are, the length of stay is usually two weeks to three weeks depending on patient's medical necessity with diagnosis and abilities in rehab.

Some skilled care rehabs are a little more lenient with admissions as long as basic diagnostic and medical need criteria for Medicare reimbursement is met.

My LO went from GeriPsych to long term care with no problems which actually surprised me as I thought there would be a lot of upset, but it went smoothly; I so hope that your LOs course of care will be a good one and a calm one.

Let us know how it goes,

J.

Thank you for the thougtful reply, J. 

Actually, her blood pressure has mostly stabilized to under 140 now. It is possible that since they put her on 4 new meds all at once, that caused instability -- although it was off-the-chart high while in geri psych before they started the new meds.  I wondered if the hospital had caused Clonidine withdrawal syndrome. They missed her regular Clonidine (AM & PM doses) when she first moved to the current geri psych. Then, for some unexplained reason, they abruptly took her off Clonidine (which she has been on for years) and replaced that with some other bp med, and added yet another. Clonidine apparently is notorious for having nasty withdrawal side effects. (See attached.)  

Update: On 1/3/2023, her AM bp was 197/76! Ugh. It is back up high again, several readings >160; but there was a 103/58 reading once. So, no idea. 

----

I'm still quite upset about geri psych putting her on 2 dementia drugs (at all) at the same time as putting her on AM & PM doses of Olanzapine, along with a new med Mirtazipine, PM. That is just too much all at once, and how do you know what is really working!  Plus, the Florida SNFs are very hesitant to take patient on any antipsychotics if it is for diagnosis of dementia, considering it chemical restraint. She's been there 6 weeks now. If they spent all this time trying to wean her off/down the antipsychotic and trying non-pharma measures to ease agitation, it would have been nice. But, alas.

I do hope that her transition from geri psych to LTC can be as smooth as your experience. (I wish that for all.) Cheers.