Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in Intensive Care!
This is another episode of “YOUR QUESTIONS ANSWERED“ and in last week’s episode I answered another question from our readers and the question was
Why Is It Important for My Mom-in-Law to Be Mobilized to Wean Her Off the Ventilator?
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer questions from one of my clients Eric, as part of my 1:1 consulting and advocacy. Eric’s mother-in-law is in a step-down ICU, and he is asking how he can stop the ICU team from pushing his mom-in-law out to LTAC.
How Can I Stop the ICU Team from Pushing My Mom-In-Law Out to LTAC?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Eric here.”
Eric: Hi Patrik!
Patrik: Hi Eric! How’s your mom-in-law?
Eric: She’s opening her eyes every day just not consistently and some days just a little bit more than others, so I don’t know, we got to give her time.
Patrik: Of course. And she’s still in ICU?
Eric: What happened is they were going to transfer her when we told you they were going to transfer her.
Patrik: Yeah, yes.
Eric: Okay, so she was in the ICU, and they were going to try to transfer her to long-term acute facility but then her insurance didn’t approve it.
Eric: So, what they ended up doing instead is they kept her there for a few days and then they put her in another room upstairs in the hospital.
Eric: … where the ratio was different, it’s four is to one, and it was a different type of care, but she’s still at the same hospital, which is good.
Eric: Yeah, so now we’re encountering a few problems and that’s kind of why I wanted to talk to you to see if you had some insights. So what they’re trying to do, first of all, they’re, obviously, trying to get her out of there.
Patrik: Yes, yep.
Eric: … she’s been there for about a month.
Eric: So, they’re trying to put her in a long-term acute facility, the one that we showed you. She has two health insurances.
Eric: And the insurance that she’s under did approve the long-term facility, the acute one, so what they’re trying to do is they’re trying to push her to a nursing facility which is a step below to that.
Patrik: Oh, I see. Yes.
Eric: So, what’s happening is we talked to a few people, and they said that if we take her off the secondary insurance, her first insurance would be approved in a lot more places. The thing is we’re going to do that so she has more options, but the first insurance is not going to kick in until next month, so the problem that we’re having now is she’s at the hospital and they’re not going to be able to transfer her into a long-term acute facility until next month when the insurance kicks in, and we don’t know if they’ll hold her at the hospital until that happens. So I guess I wanted to know if you know like how we can fight for her to stay longer or do you even think that’s a possibility.
Patrik: Yeah, I’m actually very surprised that they didn’t approve of this because… Let me ask you this before I can answer your questions. Tell me a little bit more about your mother-in-law’s condition now, is she still on a ventilator, is she still on trach? Tell me a little bit more because some of my answers will depend on what she’s doing clinically.
Eric: Yeah. She has the PEG, so she’s eating through is stomach, directly through her stomach, she has the trach and pretty much all day long she’s breathing on her own, and then they put her on at night. I mean, she could go at night, but I feel like she gets a little bit tired. What else? I mean, like I said, she opens her eyes every day, it’s not very consistent, some days she’s moving her arms a little bit more. The thing is that she’s still not really responding to commands.
Eric: … and she’s still not consistent with her progress, right? Like, a lot of times the doctors walk in and when they walk in, they can’t really see anything, so under the nose it probably looks she’s doing less than what she’s doing, but we see… like for example, this is the first week that she entirely has been off sedation and this is the first week out of the entire month where she has opened her eyes every single day. So, it’s really slow progress, but that’s progress that we see and they don’t.
Patrik: Yeah, selective seeing. Okay, and is she getting mobilized, is she getting out of bed?
Eric: They’re not really mobilizing her there. I mean, we requested physical therapy and they’re not really bringing it in.
Patrik: Yes, right.
Eric: But that’s another reason why we really want to try to fight to take her to long-term acute because it’s not the best to take her there, but they’re probably going to do more there than what they’re going to do at a nursing facility.
Patrik: What area is she in at the moment in hospital? Is it step-down ICU still?
Eric: It’s a step-down from ICU. At first, she was in CCU, then they took her to ICU and then she took a step down.
Patrik: Right, and I’m pretty sure when we last spoke, she was in the same area, is that correct?
Eric: When we last spoke, she was in CCU and they were trying to kick her out to the long-term acute facility, but that didn’t happen.
- Quick tip for families in ICU:Finding out my mom may not be as bad as I’ve been told by the ICU team
Patrik: Right. Okay. I’m really surprised that the insurance didn’t approve of that because I do believe that what they’re paying for at the moment is more expensive than LTAC.
Eric: The thing is that this is what we discovered, she has an extra insurance.
Patrik: Yeah, okay.
Eric: So, everything is being managed by that extra insurance, and not with the insurance that can bring her to LTAC. So, we’re fighting the insurance on their decision because we don’t think it’s right, and then what we’re going to do is we’re going to take her off that insurance.
Eric: I don’t know if we can fight somehow for her to stay a bit in the hospital for another four weeks before they move her.
Patrik: Yep, yep. So, have they given you a discharge date?
Eric: They didn’t, what the caseworker said today, she said, “We got her approved to two nursing facilities.” She said, “We’re not rushing out of the door, but we need you to go look at them and tell us where you want her to go.” And I told the caseworker like, “Look, listen, we’re really trying to get her on so she gets approved for the long-term acute facility, we really need you and we would love if you could fight for us so that she can stay here until we can get that approved.” And she said, “Look, I’m going to do everything in my power, but the doctors usually don’t fight with that because she already has another place to go to,” like she’s already approved to go to two other facilities through her insurance, so they’re going to try to kick her out, so I just want to prepare to see if there’s anything we can do.
Patrik: Yeah, no, definitely. So, the next step for to do is ask them for their discharge policy. So why am I saying that? So everything in a hospital works on a policy, right?
Patrik: Mopping the floor, cleaning the windows, everything has a policy in a hospital, right?
Patrik: Including discharging a patient to another facility. Now, I argue that once you have access to that discharge policy, the policy will suggest something along the lines of that it can’t happen without family consent or without patient consent. I guess in this situation, it’s without family consent because you mother-in-law’s probably not in a position to make her own decisions at the moment. Is that correct? Is that correct, that your mother-in-law is not in a position to make her own decisions at the moment?
Eric: No, she’s not.
Patrik: Yeah, okay, then it falls back to the next of kin or to the power of attorney, right?
Eric: So, you thinking that discharge policy, it will say they cannot do it unless we approve it?
Patrik: Very much so. Unless, there is an exception to the rule. The exception to the rule would be if your mother-in-law doesn’t need ICU and if she was well enough and she would a hospital discharge, that would be different story. But given the clinical situation, I think it would stand on solid grounds. That’s number one.
Eric: Let me read you this because I think it could be helpful for you.
Patrik: Yep, sure.
Eric: So the second insurance says, “Your request was denied because we receive a request from your physician to transfer you to a long-term acute care hospital after your recent hospitalization for cardiac arrest and brain injury. Our medical director reviewed your medical records and had a discussion with your doctor, and they agree that you do not require complex medical management at this time. You no longer require intensive breathing support, your continuous positive airway pressure (CPAP) used at night can be safely monitored in a skilled nursing facility. The required skill rehab and nursing services can be basically and effectively be provided at a lower level of care and therefore the request for long-term acute facility admission is denied.”
Patrik: Okay, okay. And that’s it, anything else?
Eric: No, that’s, honestly all they said.
Patrik: Yeah, okay. What’s the obstacle of your mother-in-law going on to 1st insurance, what’s the obstacle?
Eric: It’s not an obstacle, all we have to do is we have to ask the extra insurance to stop being our service provider and then automatically she would go on with only one. The problem is that this is not going to happen for another month. If we do it today, she’s going to be stay with the second health insurance for another month.
Patrik: Have you spoken to the insurance company?
Eric: We haven’t, but what we’re going to try to do is if they try to kick her out, we’re going to try to appeal it because we don’t think it’s fair.
Patrik: Yeah, no, (A) you should appeal it, (B) you should get the health insurance company in the picture as quickly as possible, that would be my recommendation, (C) ask for the discharge policy, (D) I will send you a document and I’ll tell what document that I will be sending you. I don’t know whether you and I spoke about that we providing a service here, Intensive Care at Home, have I explained that to you?
Patrik: So, we provide these services, what we believe, on an evidence-based assumption, the evidence that was published on our website, and I will send you a link to it, is that anybody on a ventilator with a tracheostomy should be looked after by a critical care nurse with a minimum of two years critical care nursing experience on a one-to-one basis, right?
Patrik: This is an evidence-based paper and when we take patients home from intensive care and look after them at home, they have a critical care nurse 24 hours a day with a minimum of two years ICU nursing experience, okay?
Patrik: Everything less than that is unsafe. Now, if we take those guidelines as the gold standard, then she will be going into environment that’s unsafe. Now, I do understand that the system in the U.S. is geared towards LTAC and then skilled nursing facility, but that doesn’t mean, (A) it’s the right system, that doesn’t mean, (B) you shouldn’t challenge it.
Eric: Right. There’s too much politics here.
Patrik: Oh, look, healthcare is not easy either, don’t get me wrong, we have to fight for everything that our clients get as well, there’s no freebies here either. But at least we are leaning on something that we think is very substantial and what they’re not telling you is that people who don’t have that level or care.
Patrik: So we know from experience that the outcomes are LTACs or in skilled nursing facilities are not good and people bounce back into ICU all the time, I think you should challenge on that assumption too, that a lot of people bounce back into ICU and there’s guarantee.
Patrik: Right, and how far away is the LTAC from where you are?
Eric: I mean, it’s pretty far, we’re not really happy about it?
Eric: It’s like, I don’t know, 45 minutes to an hour.
Patrik: Okay, and at the moment, it’s not far for you to go to the hospital?
Eric: Yeah, I mean, it’s really far to go to the hospital, but we know that at the hospital She’s getting better treatment, so-
Patrik: Yeah, yeah, sure. Sure.
Patrik: Okay, but distance is definitely something you should challenge on. There are all sorts of things you can challenge on, so you can probably even challenge on have you looked up online reviews for this particular place?
Eric: Not yet. They just told us today what they are.
Patrik: Right, well, have a look for the online reviews, that will probably give you enough ammunition to challenge.
Eric: And who do we challenge this with, the head of the hospitals or manager?
Patrik: Yeah, probably with the head of the hospital, with the insurance, you should be challenging that on a number of levels.
Eric: What other fighting points do we have?
Patrik: Yeah, so at the moment in the stepdown ICU, what’s the nurse-to-patient ratio, 1:2?
Eric: It’s 1:4, 1:2 was CCU and then now 1:4.
Patrik: Why? Okay, that’s not great because most of the time, people go from ICU, step-down ICU from 1:2 to then LTAC, or a skilled nursing facility to 1:4, I would imagine that in a skilled nursing facility, it’s worse than 1:4.
Eric: I’m assuming because it’s 1:4 here and it would be 1:4 in the LTAC, so I’m assuming because this skilled facility is a step-down it’s going to be, I don’t know, 1:6, 1:8.
Patrik: Yeah, something like that, and probably-
Eric: And those places have horrible reviews. They’re horrible.
Patrik: Right. Oh, no question there, they’re horrible in other places too and it’s probably a 1:10 overnight.
The 1:1 consulting session will continue in next week’s episode.
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- How to ask the doctors and the nurses the right questions
- Discover the many competing interests in Intensive Care and how your critically ill loved one’s treatment may depend on those competing interests
- How to Eliminate fear, frustration, stress, struggle and vulnerability even if your loved one is dying
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- How to stop being intimidated by the Intensive Care team and how you will be seen as equals
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- How you need to manage doctors and nurses in Intensive Care (it’s not what you think)
Thank you for tuning into this week’s YOUR QUESTIONS ANSWERED episode and I’ll see you again in another update next week!
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This is Patrik Hutzel from INTENSIVECAREHOTLINE.COM and I’ll see you again next week with another update!
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