Many elderly patients get admitted to the hospital with profound weakness due to their acute and chronic medical conditions. Many of them will leave the hospital with profound weakness from their acute and chronic medical conditions (and unfortunately without a palliative care consult). In many situations, these patients will be too weak to take care of themselves. They will need extra help with their activities of daily living either from family or from trained home health care representatives. Patients who cannot safely return to the community often need to transition through a nursing home (with skilled nurses) before returning home. These are called skilled nursing facilities, or SNF for short (prounounced sniff).
If you're going to a SNF, that means you're going to a nursing home to receive a combination of physical therapy, occupational therapy, speech therapy or other therapies intended to get you back to the community. This SNF status is paid for by the Medicare National Bank and your supplemental insurance for up to 100 days per benefit period. There are many rules that must be met in order for Medicare to pay for these benefits, but that's the subject of another discussion.
Let us say you or your family member has met the criteria to have their SNF benefits paid for by Medicare. Let us say the physical and occupational therapists at the hospital you have been admitted to are recommending that you or your loved one transition to a skilled nursing facility upon discharge from the hospital because they do not feel you or your loved one can safely be discharged to home to provide self directed activities of daily living. Let us say you or your family member does not want you to go to a nursing home or a SNF or an assisted living facility or anywhere other than home.
Can a hospital force a patient to go to a long term nursing facility or short term skilled nursing facility (SNF)? The answer is no. No doctor, no nurse, no physical, occupational or speech therapist anywhere in America can force you or your loved one to go anywhere you or they don't want to go. If a patient wants to go home against the recommendations of their medical team, they have every right to go home, with one caveat. They have to have the capacity to make their own medical decisions or have a surrogate decision maker allowing discharge to home against the recommendations of the medical team.
For many elderly folks, giving up their independence and being forced into a nursing home is their biggest fear. If there are any elderly folks reading the Happy Hospitalist, remember, nobody can ever force you to go anywhere you don't want to go, as long as you have the capacity to make your own medical decision. Your doctor can't force you. Your nurse can't force you. Even your powers of attorney can't force you. If your family is telling you you have to go to a nursing home or skilled nursing facility and you don't want to and you have the capacity to make that decision, no matter how poor that decision is, you have the right to go home against everyone's wishes. End of story. Tell them to get lost.
However, if you have been deemed unable to make your own medical decisions because you lack the capacity to do so, and you have a powers of attorney (POA), your POA can force you to go anywhere they want you to go, whether you agree to it or not. Who makes the decision on whether you have the capacity or not to make your own decisions?
Scarily enough, any licensed physician can make that decision even though most physicians have never been formally trained in the process. Your hospitalist could make that decision. Your family doctor could make that decision. Your surgeon could document your lack of capacity to be involved in your own medical decision making. Even your dermatologist could deem you incapable of making your own medical decisions. If there is any question, I usually get a specialist (psychiatrist or psychologist trained in this process) to document a patient's capacity status.
If you do not have a POA and you have been determined to lack the capacity to make your own medical decisions, then a court must establish a guardian through the direction of family guidance. If you do not have any family for guidance, the court will assign a guardian for you, usually a lawyer who knows nothing about you. Establishing a guardian is a court process that comes with expenses. It is not free. If you have no family, no POA and the hospital has to establish a guardian for you, and that guardian recommends a nursing home (which they will if the hospital recommends it), then that is the only circumstance where a hospital can force you to go to a nursing home or skilled nursing facility.
I implore everyone to get a POA. If you're in the hospital, you can get these forms from the hospital. You can also find free POA forms off the internet. Discuss your wishes with your POA so they will always make decisions for you that are consistent with your wishes should the time come someday that you can not. Otherwise some family member may force your doctors to resuscitate your decomposing body over and over again just to document your time of death past the midnight hour so they could collect one last VA disability check from your cold dead body. Yes, that really happened to me.
Oh and one other thing. If you are in a nursing home or skilled nursing facility and you want to leave them against the medical advice of your doctor, Medicare will pay for all care you received up to that point. Don't let anyone tell you that if you left, Medicare won't pay for the care you already received and you may get a bill. There is no truth to that statement. You have nothing to worry about. Nursing homes are not prisons. I don't know who widespread this misinformation is in skilled nursing facilities, but a reader contacted me with their dilemma. What a tragedy. Here is their comment:
I wanted to give you a quick synopsis of my situation to make sure I have my facts straight. I am POA for my mom and was told by the director of a SNF she went to after a three week hospital stay that she would get a "$15,000 bill from Medicare if she were to go home". That didn't sound right to me and don't know if it was more of a scare tactic directed toward her so she would feel obligated to stay. She is presently in a SNF that I don't feel is conducive to her recovery at this point. A visiting physician I talked with also agreed with me. I recognize her need for a caregiver at home and feel she would be better off finishing her recovery there. My only worry was the comment made by the director that she would get slapped with a huge bill from Medicare if she were to leave. I just wanted to make sure I wouldn't be breaking some kind of Medicare protocol and be on the hook for prior services received. Any advice you could give me would be helpful.This was my response:
Medicare pays for claims based on medical necessity. If your loved one's stay has been medically necessary up to the point they leave, Medicare should pay the nursing home and doctors for the care they have provided up to that point. If you choose to take your loved one out of a facility against the advice of the physician, that is your right to do so. We do not put our loved ones into locked up prisons. While I cannot comment on the specific details of your case, I cannot think of a circumstance where the care they have already been provided with will not get covered. If a director of a SNF told me my mother would get stuck with a $15K bill for taking her home against the advice of her physician I would ask the director of this facility to provide me with a resource to investigate that claim myself that they are using to make the same claim. I would also contact my Medicare claims provider and ask them the same thing and tell them the name of the facility and the person telling you that Medicare will not pay if you take your loved one out against their advice. I think Medicare would want to know what kind of distress this home is putting you and your mother under. I would also contact my local newspaper and perhaps my county attorney and tell them my story. It sounds like something that may be either illegal or immoral. Either way, if they are saying this to you, they are probably saying it to others either out of ignorance or the need to keep their beds filled. Perhaps a local news person could provide the right answer for many other loved ones in your community.Remember, America is not a police state, yet. You have every right to leave a nursing home at any time, so long as you have the capacity to make that decision and you aren't going to be on the hook from Medicare for medically necessary services already received. And if you don't have the ability to make your own decisions, your POA or guardian has every right to release you too without any risk of getting a bill for care already received.