Previous segments described my fall from the grace of wholeness, and my experience as a recipient of skilled nursing. This blog gives vignettes that touch on three issues of concern to everyone healing from a serious medical condition. These are: recovery worries that distract you from healing; health insurance; and life planning discussions within the nursing facility.
Personal note as of May 1: My Michigan orthopedic surgeon is unsure about how well my repaired hip socket will function. Nevertheless, he authorized physical therapy and relaxed my walking restriction to WBAT (weight bearing as tolerated). That is, 100% weight bearing provided I can stand it. This will allow me to re-build muscle and start unassisted walking. He also authorized active ROM (range of motion) but not passive ROM therapy. In other words, if I can perform a task without pain, OK; but the therapist should not move me to amplify my range of motion. After my pelvis heals further and my pain-free range of motion is clear, my best path back to “normal” will clarify. Incidentally, I’m amazed to report that my skilled nursing facility in Honolulu (The Villas) has phoned me three (!) times to verify that I have seen my Michigan doctors and that I am continuing to heal with the help of physical therapy.
Vignette 1: Recovery Worries To Keep You Awake
To first order, being confined in a rehab nursing facility for several months pre-determines one’s life. There’s a regular schedule of breakfast, lunch and dinner, plus occupational and physical therapy, plus medications, plus recording your “vital signs”. (At The Villas, the vital signs routinely recorded are blood pressure, pulse rate, peripheral blood oxygen saturation and oral temperature.) In addition, therapy is so tiring that you (I, at least) often want to take a nap.
Thus, outside forces largely define the resident’s schedule. Nothing to worry about – right?
Wrong. You are the custodian of your own body. If you don’t keep it functioning smoothly, the medical staff will take over and you may not like the results.
Recovery Worries for Every Resident
Some recovery worries are almost universal and definitely deserve your attention:
- Keep Your Poop Moving. If you had surgery, during anesthesia all of your systems shut down. You must coax them to start up again. Even if you weren’t unconscious, in a nursing facility you are much less active than in normal life. That low activity disrupts your usual balance of food intake, activity and bathroom visits. Load your diet with fiber and be as active as you can be, to get onto a regular schedule. The nurse aides will record every instance of your poop (or lack thereof). If you have too much or too little digestive movement, expect to receive some uncomfortable medications to cause you to be regular again.
- Get Rid of Water Bloat. Do your legs look like they belong to a person twice your size? That is edema or water bloat, one of the common recovery worries of people who spend too much time in a bed. Elevate the offending parts and if necessary, accept some diuretics to get your water back to normal. Edema interferes with the body’s normal healing processes.
- Prevent Pain. A healthcare facility does not want you to have pain. Moreover, they will advise you: if you feel pain beginning, report it immediately! It is easier for them to stop the pain early on, before it becomes established. I personally do not want to take strong pain meds, and have thus far not had to. However, I have sometimes taken Tylenol prior to a physical therapy session. Tylenol has also helped me sleep if the day’s therapy leaves me with nighttime aches.
- Bedsores. If you spend periods of time lying still or sitting in a wheelchair, you may develop pressure ulcers or bedsores. These occur because localized pressure points cut off blood circulation to your skin. Bedsores can also arise from friction, sliding or persistent moisture. Because I was almost immobile at the hospital following my hip surgery, I arrived at The Villas with an emerging bedsore just above my tailbone. The nurses helped me cure it within two weeks with the help of skin cream plus shifting bed wedges and pillows. My back also broke out with a rash, which the nurses remedied with a cortisone cream.
For Gentlemen Only
A couple of patient concerns are, in my experience, more a problem for men:
- Urinary Catheter. For some reason, whenever I have surgery, the surgeon finds it necessary to install a urinary catheter. The medical reasons vary, but the result is still chafing and annoying. Removing the catheter is always at the top of my list of requests to the doctor. For my heart operation and my hip repair, they removed it within 3 days, which was still 3 days too long for me. Unfortunately, not everyone can pee regularly without the help of a catheter. The reason may be an infection, internal damage or a urinary stone. Therefore, the nurse aides observe and record your every urination to make sure they don’t have to treat some more serious problem.
- Itchy Privates. A hospital and a nursing facility are happy to provide sanitary disposable paper underpants. You might think that being able to change your underwear often sounds like a good way to stay clean and ward off infection. Yeah, I thought so too. However, then my scrotum got itchy. The nurse provided body powder (corn starch) which helped, but only to a point. I concluded that paper underpants and a scrotum are inherently a bad combination. I was much more comfortable returning to my own cotton briefs.
Your Unique Concerns
You are a one-of-a-kind individual and you will have other specific concerns that you need to take charge of. Just to illustrate, here are three recovery worries that I fretted about:
- Preventing GERD. After many years my doctors have figured out how to prevent me from having gastric reflux (GERD). I agitated at rehab until the docs added the necessary meds (ranitidine morning and night) to my daily regimen.
- Just-Right Hemoglobin. During my hip surgery I lost a lot of blood but was not transfused. Three days after surgery my hemoglobin had fallen to 8 so Queen’s transfused me with 2 units of blood. They then started me on a substantial daily dose of iron, which after five weeks brought me back to a normal male hemoglobin level (14 to 17). I annoyed my doctors and nurses into tracking my hemoglobin so that they could stop the iron supplement before my hemoglobin got too high. (I already knew from my recovery from heart surgery, that iron supplementation could push my hemoglobin above normal if continued for too long.)
- Weight Loss. My normal weight of 180 pounds fell below 170 after 3 weeks at The Villas. Unexplained weight loss is an alarming symptom, and was a key feature of my heart infection in 2017. However, this current weight loss was not unexplained. For weeks after surgery I was losing mass from the muscles I was not allowed to exercise. I made a point to eat plenty of food, and got the nurse aides to take my weight almost daily until it stabilized. Now at home, I’m around 165. Presumably that will climb as I rebuild muscle. One of my Michigan docs has told me that it’s not surprising to lose 10 or more pounds of muscle due to non-use after an injury.
Vignette 2: The Tug-of-War Between Rehab and Insurance Reimbursement
Among recovery worries is the question, what is all this care going to cost me? If you are unfortunate enough to have an injury like mine that requires a long time to heal, you may learn of an ongoing battle that confuses medical care. The battle is conducted between the rehab therapy people and the insurance claims staff.
In my case, the insurance is Medicare plus a Medicare Supplement policy from AARP, plus a long term care policy.
Recovery Worries with Lengthy Rehab
A hip replacement would have allowed a fairly quick recovery. However, a broken pelvis like mine does not heal for 8 to 12 weeks. For the first five weeks I was limited to “toe touch weight bearing” (TTWB). That meant that my left foot could not press on the floor with a force of more than 10% of my body weight, i.e. 18 pounds. Thus, whenever I walked I had to hold my left hip and left foot up so that they barely grazed the floor. This was a sure recipe for a stiff hip that resisted straightening, and a left hamstring that kept cramping.
I was happy to learn that when you have been in the hospital, Medicare pays for up to 100 days (14+ weeks) of rehab therapy. The first 20 days are 100% paid, the next 80 days have a $170.50 per day co-pay which in my case is covered by AARP.
The “Up To” Phrase
However, the key condition to the coverage quoted above is coverage “up to 100 days.” Medicare wants to see some kind of progress as a result of the therapy. Therapists are caught in a bind: delivering therapy that genuinely helps the patient get fully healed; while at the same time reporting progress in a way that Medicare deems to be reimbursable.
I completed five weeks of physical and occupational therapy. My doctor then studied my x-rays to see how well my hip socket was knitting. As a result, he allowed me to put 50% of my weight on my left foot, and that gave the therapists the excuse to treat me for an additional two weeks. However, that was the end of my in-patient insurance coverage. Thus, despite the “100 days” rule and my recovery worries, Medicare rules would not support me in a nursing facility until I was 100% recovered.
With my 50% weight bearing allowance, the doctors and therapists decided that I could safely travel back to Michigan and handle the stairs in our house, with the help of a walker and crutches. Thus they discharged me from the SNF, which ended my Medicare authorization for in-patient treatment.
Back in Michigan, my orthopedist has prescribed out-patient physical therapy, allowing 100% weight bearing. I understand that Medicare part B will pay for $2,040 of this extra therapy, about 18 to 20 sessions. That’s over two months, which should be sufficient. However, if I have a “medical need” for still more therapy, my long term care insurance will cover it.
Vignette 3: Life Planning While in the Nursing Facility
I previously mentioned that one must give up any desire for privacy in a hospital. The same is true in a skilled nursing facility, especially if you occupy a “semi-private” room.
If you haven’t yet had the pleasure of the experience, I will inform you that semi-private is not at all private. The Villas’ information booklet suggests that when residents have visitors, they go to a large public lounge or to a meeting room. That ensures that they don’t disturb the roommate, and also gives them privacy for their discussions. But in fact, no one adheres to this advice: visitors often meet with the resident and ignore whoever else may be in the neighborhood. Therefore, I could not help hearing, and learning from, some very personal discussions.
We have previously discussed the need for senior life planning well in advance of need. However, in reality many patients in a skilled nursing facility find themselves considering, or reconsidering, where and how they will live next.
Mr. Z, whom I met, was such a patient. He had many conversations with his adult children and with people who wanted him to come and live at their property. Those who want the full monty can see Medicare’s alternatives to nursing homes. I will confine my discussion to Mr. Z’s options.
Mr. Z’s Alternatives
- Home Care. Mr. Z would live at home, with help and a housemate. However, that’s what Mr. Z had been doing when he had a medical crisis without anyone near to help him. No one in his family wanted to repeat that experience!
- Board and Care Homes. Mr. Z would live in a “group home” with a handful of other seniors. The homeowner would provide some help with ADLs but no nursing care. A nurse visits the home once a month – not very often! – or by appointment. However, Mr. Z has medical conditions requiring skilled care, so a group home would probably not accept him.
- Assisted Living. The care available at assisted living facilities varies quite a bit, from very little to services approaching a skilled nursing facility. This was deemed an expensive option since insurance would not cover most of the cost.
- Hospice Care. Mr. Z’s heart condition is serious enough that he could qualify for Medicare-paid hospice care, either in a hospice facility or a SNF. What would be required is for his doctor to certify that he is terminally ill with life expectancy of 6 months. Mr. Z could continue to receive his “maintenance” heart medications, but not forward-looking care such as physical therapy. Although we tend to think of hospice care as terminal, that need not be the case. I heard of an example where a man entered hospice and stopped taking a number of supposedly necessary prescriptions. His body responded very well to the reduction in meds. He made a remarkable recovery and left hospice for assisted living.
And May I Have the Envelope…
When I most recently spoke with Mr. Z, he and his family were leaning toward hospice care for his next residence.
If Mr. Z’s condition improves, he can leave hospice and choose another living option. On the other hand, if he lives past the 6 months but his condition is still terminal, he can be re-certified for an additional 6 months of Medicare hospice coverage.
Thus I learned that due to Medicare insurance rules, hospice care is yet one more option to alleviate recovery worries. Hospice is worth considering because it can extend a patient’s eligibility for insurance reimbursement.