What Happens When My Aging Parent is Discharged From the Hospital?

Transcript of Interview: “What Happens When My Aging Parent is Discharged From the Hospital?”

Mike Barnes: We teach ourselves and our kids at an early age to be prepared, to be ready for anything. But we’re not always ready for that with Mom or Dad because what if they go to the hospital? What comes next? 

Kim Barnes: Today, we’re bringing in John Brown from Oasis Senior Advisors Austin Central Texas. Thanks so much for being with us today.

John Brown: Thanks for having me, great to be here.

Kim Barnes: We know that, unfortunately, it might happen—our parents are going to need to go to the hospital. We know to take them there if they have an emergency, but a lot of times, I think there’s a lot of confusion about what’s going to happen next. Do they go home, or are they going to have to go somewhere else? So where do we start with that?

John Brown: Well, I think first you have to have a little understanding about the hospital system now compared to years past. The average stay in a hospital now is about three days, down from seven or eight days just a few years back.

Kim Barnes: Wow.

John Brown: So that’s one thing to remember: it is a fast pace. They’re going to treat the condition, whatever Mom or Dad’s condition is, and then they’re going to start moving toward that discharge. Before we can even get to where Mom or Dad can go, we have to address how they’re doing, what the medical condition is, and if it’s being treated. Once it’s treated, okay, now we have to know our options and where to go from there. But the clock starts the minute you enter the hospital, and these shorter stays are definitely causing a lot of stress for families. While you’re calling your kids, your grandkids, or Aunt Jo or whoever, and letting them know about Mom, you find out, wait a minute, we’re already moving, we’re already being discharged. So you’ve got to start by having a real conversation when you’re in the hospital. Ask who is going to be helping with the discharge—is it a social worker, a discharge planner, a case manager? They have different titles, but there will be somebody who is going to communicate with you. So you need to immediately make sure you’re in contact with them, you’ve connected with them, and they have a good number to reach you or whoever is going to be handling those conversations. And then answer the phone—that’s probably one of the biggest things. We hear stories from the hospital, “I’ve called for two days, and they haven’t called me back.” Once that happens, things can get out of control real fast.

Kim Barnes: So, you’re going to have those conversations, and what are you going to tell them? Are you going to tell them more about what the home situation is like, where they typically live, if you don’t think it’s safe for them to go home by themselves, or if their loved one isn’t able to take care of them? What do you need to tell them?

John Brown: Absolutely. What is going on at home? Who is there to help if they’re at home? Who can care for them? Who can’t care for them? Also, if they’re living in assisted living, is it Type A or Type B? Does it have memory care? If they’re in independent living, what does that look like? You’ve got to have this conversation about where they’re living and what’s been going on. For example, “I’ve noticed Mom’s been struggling a lot with her gait and walking,” or “We’re having some problems keeping her consistent with her medication.” Just give that little story of what’s going on because the more the hospital knows, the more they can help with the discharge process, and they won’t make any assumptions that everything is going to be okay when it might not be.

Mike Barnes: But it’s not up to us to determine whether they should go to a skilled nursing facility or rehab. They make that choice, but we can kind of fight if we don’t agree with it, right?

John Brown: You can advocate. The physician is going to give a recommendation. For example, they might say, “I think Aunt Sue needs to go to a skilled nursing or inpatient rehab,” or “I think she needs memory care.” They’re going to make that recommendation, but ultimately, it comes down to how the disease or accident is treated, what the recovery standard is, and how they’re going to do in rehab. If they’re going to rehab, there are a lot of variables in there. The physician makes those recommendations, and then it comes down to your Medicare coverage, which will have a huge impact on what options are available to you and what’s covered.

Kim Barnes: Can you give us a sense of what the main options are generally when you’re being discharged from the hospital?

John Brown: Of course. There’s home with home care and maybe home health or other ancillary services. You’ve got inpatient rehab, which is that fast rehab—three hours a day for about 10 to 14 days, trying to get them as strong as we can as fast as we can. Then you have skilled nursing, which is slower rehab. It’s basically one hour a day of all three disciplines: physical therapy, occupational therapy, and speech therapy. Then, of course, you have senior living. With the transformation of healthcare and senior living, you’re really starting to see those lines blur. Some senior communities have on-premise therapy five days a week, so you can get the same benefit of skilled nursing in a community. They also have physicians that visit their communities or actual doctors’ clinics in the community. Lastly, there are some scenarios where you could go to an acute hospital, like if someone has a really bad viral infection and they’re going to need IVs for the next 30 days. That’s complex medical care, so you might go to an acute hospital. Those are pretty much your options—home, inpatient rehab, skilled nursing, acute hospital, or senior living options that could meet all those needs.

Kim Barnes: If you think, “I think Mom needs to go to rehab because she needs to get better fast—she broke a hip, she’s had surgery, we want to get her up on her feet quickly,” but they say, “No, we really think she needs skilled nursing,” can you advocate for rehab, or is that really going to be based on your insurance coverage?

John Brown: It’s going to be both. It really does come down to your Medicare coverage. If you have an Advantage plan, a PPO, an HMO, or supplemental insurance, they’re going to be the driver of the decisions. If they see that Mom also has mild dementia, they might say, “We don’t think she’s going to do well in inpatient rehab because she has dementia, so we’re recommending skilled nursing.” But if you really want her to get going and get as strong as possible as quickly as possible, you can advocate for inpatient rehab. Probably the best way to do that is to connect with the inpatient rehab as quickly as possible. If they feel it’s appropriate, they can advocate on your behalf. That helps you, but again, it’s how fast we get that going. We’re talking about a three or four-day window here, so if we have to do appeals and things like that, the time gets cut real short.

Mike Barnes: It’s so hard to understand Medicare, so I’m not advocating that we try to learn all of that, but it’s good to have the policy or the information in your caregiver’s key or something like that so you can show the case manager or the doctor and let them know what Medicare is going to be able to cover, correct?

John Brown: Correct, and I think 90% of the time when you enter the hospital, they have all that information, but you’re probably going to be the one that’s picking up the phone and calling them and asking questions. So, take pictures of the cards. We always recommend, like your caregiver guide recommends, to always have a copy of their Medicare coverage cards, their VA card, all those insurance cards. Have pictures of them front and back because you’re the one that’s going to be calling and asking questions. For example, if Mom’s in the hospital and they’re recommending skilled nursing but she went to skilled nursing before and wasn’t happy, you might want to advocate for inpatient rehab. So, make sure you have those cards readily available or have a picture on your phone because you’re going to have to do some advocating.

Kim Barnes: Are there opportunities if you feel like they’re telling you, “Well, we think she’s fine to go home,” but you really don’t think it’s safe? How do you approach that? Can they still send her home if it’s really not a safe environment? Do you have an example of that?

John Brown: Yes, recently we had a lady who had had a stroke, and I felt it was a pretty major stroke—she was bedbound at that time. They were just moving to discharge her to send her home, but once I spoke to the family, I did not feel that was appropriate. Her husband was 92 years old, and he couldn’t take care of her. She was a fairly large woman, over 200 pounds, and he just was not going to be able to take care of her, and there was nobody else there that could do it. So, we had the discussion with the family, explained the different types of rehab, got an inpatient rehab on the phone, and got them to advocate. From the hospital, they discharged her to inpatient rehab, and miraculously, 14 days later, she walked out of rehab with a walker, but on her own. Whereas if she had gone home, it would have been a readmission within 24 to 48 hours because there was not enough care at home. But the hospital didn’t have these discussions because the family hadn’t connected with them and explained the circumstances. Once I spoke to them and told them what to say, how to say it, and who to ask for, they made that connection, and it happened very quickly. But again, you’ve got to advocate and start that process fairly quickly.

Kim Barnes: And you’ve got to start fast. You can’t wait until it’s time to sign the discharge papers and then say, “Oh, hold on, hold on.” This is also where we can have those conversations with the social worker and the case manager, but if we’re just overwhelmed, we can reach out to a senior care advisor like yourself to help us understand because it is so confusing—all the different terms and possibilities.

John Brown: Absolutely. We’re always here to help a family. Our goal is to help a family through that process. You have lots of options, and you can advocate. You know your loved one better than anybody else, so it’s really about being honest, telling everybody what’s going on, and knowing what to say and when to say it. That’s a big piece of it. If you don’t have a plan—which we always recommend—you should know your nearby rehab that you like. If Mom or Dad needs a respite day or an assisted living stay, have one picked out because if you don’t, the hospital will make assumptions and move to those discharge plans. The easy button for them is either skilled nursing or home, so if you don’t say yay or nay or communicate to them, that’s what they’re going to do. They’re going to come to you and say, “Here are the three places your insurance covers. Which one do you want?” The nearest one could be 40 miles away, so you’ve got to have these discussions and have a plan.

Kim Barnes: As the adult child, you don’t always know that you have the ability to have that input because you just think, “Oh, well, they know what to do.” And while they do know what to do, you still want to be a part of that conversation.

John Brown: The part they don’t know is you know Mom, and you know if Mom can do three hours a day of rehab or if she doesn’t like physical activity. You know what her life is like at home, wherever home may be. So, if you’re not communicating that, they’re assuming everything is covered at home, wherever home may be. You’ve got to make sure you paint that picture of, “Hey, she’s been struggling. We’ve noticed her gait has been really bad.” Or let’s say it’s a UTI—“She’s really struggled mobility-wise, and she’s had some mild hallucinations.” You’ve got to paint that picture because the way they look at it is, “Well, we gave her the IV, cleaned up the UTI, she’s good to go.” They don’t know that previously she was struggling with these activities of daily living. 

Kim Barnes: You’ve got to have those conversations before they’re actually discharged, whether it’s to skilled nursing, rehab, or home, because once they’re discharged, you can’t really appeal after the fact, correct?

John Brown: Correct. You can’t appeal to go back to the hospital after you’ve already transitioned to skilled nursing. You can appeal while you’re in the hospital, while you’re in skilled nursing, or in inpatient rehab or an acute hospital. But once you’ve transitioned, there’s no appeal process. Probably 50% of the time, that’s because we didn’t prepare for the discharge, so they end up going home or to wherever, and they hate it. Probably 60% of the time, they end up going back to the hospital, and it’s a readmission that just starts the whole process over. Now, everyone’s stressed out, everyone’s angry, and we worry about the seniors because all this movement is going to cause transitional decline. Any senior with even a little bit of cognitive decline—whether it’s just old age and memory or something like dementia, Alzheimer’s, Lewy body dementia, or Parkinson’s—every transition is going to lead to a decline. They’re going to get worse with each move until they get their bearings and understand what’s going on. So, we never want to have a readmission because that movement from home to hospital to skilled nursing and back to the hospital is just asking for it to get worse.

Mike Barnes: Yeah, it’s a lot. John Brown, you’re helping everyone get much better prepared. Thank you so much.

John Brown: Have a great evening.

Mike Barnes: I think that we’re learning to be prepared. We don’t want to over-prepare, but we’ve got to know a little bit about what comes next, just in case. Better safe than sorry. If there are any other topics you’d like us to discuss, please let us know. Parenting Aging Parents.

*This transcript is auto-generated. Please excuse any typos or mistakes.