Caregivers of Medicare Patients: What to Know Before a Hospital Discharge

Recently, an 88-year-old member of my family underwent elective spinal surgery for disabling back pain. While the duration of hospitalization for anyone after surgery can be unpredictable, we were surprised to find out our family member would be discharged home after only two days. We were not prepared, which led to some panic on our part, and scrambling to figure out what we needed to do to ensure our loved one's safety and well-being at home.

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This article is meant to pass along the valuable information I learned during this situation, hopefully giving family caregivers of people over 65 (Medicare beneficiaries) the time to better prepare for their loved ones’ return home from the hospital.

You can expect discharge planning (a strategy for when patients will leave the hospital and where they will go) to begin more or less immediately, even on admission. Someone else (a social worker, physical therapist, other therapists and your physician/surgeon/hospitalist) is thinking about discharge even if you are not. So, my first piece of advice is for you to think about it, too.

Even before your loved one enters the hospital, take advantage of as many patient-education opportunities as your physician provides, including classes or pamphlets about the normal recovery from a specific surgery and what will happen at discharge. If you're not offered any, ask.

Discuss with the physician all of the potential discharge scenarios, such as: immediately to home with no services; to home with in-home services, like therapy and/or nursing; or to a skilled nursing facility for further rehab before discharge to home, with or without at-home services. Ask the doctor’s opinion about which is likeliest.

Our family member’s surgery was an outstanding success. By the second day after surgery he was judged safe for all movement, with the use of a walker and a “stand-by assist” (meaning someone needed to be nearby to help). He was also medically stable.

The surgeon had initially suggested that as much as two weeks in a skilled nursing facility post-hospitalization might be in order. But after a couple of days in the hospital, this was no longer considered necessary. Our family member would be discharged to home the second day after surgery, and we found out that second day at 10 a.m. We were on our way home with him just after noon.

There are problems with such a decision. In the hospital, our loved one had access to:

• A hospital bed with hand rails and the capacity to raise and lower the height of the bed, all making getting in and out of bed easier than it might be at home
• Grab bars and a raised toilet seat in the bathroom, making toilet transfers easier than they might be at home
• Staff 24 hours a day to help him move around safely, including for the several nighttime trips to the bathroom many older patients need

When I mentioned these issues to a member of my relative’s discharge-planning team at the hospital, I was told there were no medical or rehab reasons to keep him in the hospital or any other facility.

When I asked if the same decision would be made if a patient were returning to home alone and without family support, the answer was “yes.” This was despite the fact that he lives with only his 88-year-old spouse, who is not strong enough to provide much ambulatory assistance.

This is the reality in today’s hyper-cost-conscious, and also patient-autonomy-centric, medical decision-making environment.

I am a realist: It is reasonable for everyone to try to keep hospital costs low. It is also reasonable for Medicare beneficiaries to understand some of the rules at work regarding hospital length of stay.

For example, our state’s board on aging provided me with the following information from a Medicare Benefit Policy Manual:

“In order to get Medicare coverage, including rehab in a skilled nursing facility (SNF), the beneficiary must be an inpatient in a hospital for three consecutive midnights, not including the date of discharge. If the three-midnight requirement is not met, or if the beneficiary is in an outpatient status known as 'observation,' the stay in a SNF cannot be covered by Medicare, even if the beneficiary is getting skilled services in a SNF."

A two-day hospital stay eliminates the possibility of Medicare paying for a post-acute (rehab) stay elsewhere.

Furthermore, hospitals may find they can save money on Medicare patients now and in the future if they “bundle” expenses. In bundled payments, also known as the “Bundled Payments for Care Improvement Initiative,” a hospital is held accountable for the costs of a patient’s “entire episode of care,” including hospitalization plus readmissions, post-acute care and physician and outpatient services.

While hospitalization is generally the most expensive part of the “bundle,” post-acute care (including time a patient spends in a skilled nursing facility and/or receiving in-home health services) is the second greatest expense, according to a May 2019 article in the Journal of the American Geriatrics Society.

Hospitals implementing bundled payments have reduced Medicare spending by discharging fewer patients to skilled nursing facilities and using fewer days of that care.

It is good to know that this study also reported no increase in hospital readmissions for the patients who used fewer, or no days, in post-acute care. But your family member may be coming home a critical day or two sooner than you anticipated.

You can appeal a hospital discharge decision for a Medicare beneficiary. But doing so is complicated by the urgency of an impending discharge. A Medicare representative informed me that a timely appeal was possible by contacting either Livanta or KEPRO, which are beneficiary and family-centered care quality improvement organizations that contract with Medicare.

As a former practicing physical therapist, I highly recommend placement of appropriate equipment before the patient gets home. I also recommend purchasing or renting such equipment (such as grab bars, a raised toilet seat and a shower bench) only after consulting with a physical therapist or an occupational therapist, preferably one who comes to your home.

Ask if your physician can order a home health consult before the patient’s hospitalization, and if Medicare will pay for it. Someone may tell you that the consultation is only necessary after the patient’s discharge to home. If so, explain you know it’s very possible your loved one might only be in the hospital for two days and that it often takes longer for equipment to arrive and be installed. Express your concern about how your family will manage if your loved one is discharged to home with no safety equipment in place.

Make sure your loved one, if discharged with “stand-by assist,” knows what this means: he or she needs someone nearby at all times while walking or transferring. Line up help ahead of time. If you can afford it, hire assistance.

If you have long-term care insurance, check beforehand for benefits associated with home care. Sometimes, benefits don’t start until months after an aide is privately hired.

And one final piece of advice: Discuss care with your loved one and other members of the family who may be assisting with care. Few, if any, people get more able as they age into their late 80s and 90s. Be honest and realistic about what kind of care may be necessary, particularly after a hospitalization. Your loved one and family might even consider assisted living or other long-term care community while the ability to enjoy some of its benefits co-exists with the use of its services.