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The Senior Hub Podcast is a resource hub for planning and caring well for your aging parents and loved ones. This podcast tackles everything from data, to key terms, to personal stories, to sacred moments, to tricky family dynamics.
Join hosts Daniel Alexander and Rebecca Hill as they engage their guests, and each other, on this most important topic. We are all learning about this topic as we get older. Let's do it together.
Find us at www.theseniorhub.com
Hello, and welcome to the Senior Hub podcast. I am Daniel Alexander, the founding director of The Senior Hub, and I'll be your host for today's conversation. Our hope is that each time we do this, by the time we're done, you'll feel a little more equipped and maybe even a little more hopeful for what's ahead. So without further ado, we're gonna dive in. And joining me once again is our expert, Rebecca Hill, our chief chief care strategist of The Senior Hub.
Speaker 1:Welcome, Rebecca.
Speaker 2:Hey there.
Speaker 1:For those of you who have been with us, welcome back. And for those of you joining us for the first time, welcome. Either way, let me set the stage. Throughout this podcast series, we are following one family's story because we feel like the best way to understand what aging families actually faced isn't always a list of topics. It's a real journey just like all of you are on.
Speaker 1:Our character for our series is Margaret. She's 78 years old. She lives alone in Raleigh, North Carolina. She's widowed and has three adult children, one of whom lives nearby and two are out of state. A few episodes back, Margaret fell at her house in the middle of the night, and she broke her hip, which is a common occurrence.
Speaker 1:EMS came, surgery happened to the hospital, and her family has been navigating the hospital stay ever since. At the end of our last conversation, Rebecca mentioned that a case manager would start showing up and talking about all the different options and discussions about what it looks like to discharge from the hospital, either normally to a home or to a rehab facility. Well, that conversation has arrived for Margaret's family. And when it does, they realize pretty quickly that they have no idea what their options are or what rehab stay itself will actually look like. Only thing they do know is nobody believes that it's time for Margaret to return to her house, but rather it's time for her to pursue further rehab.
Speaker 1:So today, we have two things to cover. We wanna help the family make the right decision, and then we wanna help them show up well once that decision's made. All right, so that's the preamble. Rebecca, let's start with the decision in the hospital itself. There's a lot of terminology that goes into this, a lot of different options that we're picking up about rehab.
Speaker 1:Will you start by just unpacking some of those terms and where we need to even align our minds in terms of our options?
Speaker 2:I just want to state out loud that it feels for families like a pop quiz that they didn't study for. There's terms and acronyms and just general healthcare understanding that's required, and it can often feel like a deer in headlights moment. So we wanna take away that kind of frozen behavior and start to really just understand what options are being given. You mentioned the case manager now steps into the picture. So this is your first liaison to, kind of what care has culminated within the hospital setting, and then what's being recommended clinically, for Margaret next.
Speaker 2:So, the case manager is guiding you, about what she's received and then the goals for her and next steps.
Speaker 1:Okay. So will you go ahead and unpack that just for a second? Who does the case manager work for? Where does that person come from?
Speaker 2:Case managers are rounding with doctors, and also communicating with nurses, discharge planning nurses, nurse navigators.
Speaker 1:Okay. So they are employees of the hospital.
Speaker 2:Yes.
Speaker 1:That are employed in order to help one particular case or they have a whole caseload, I would assume.
Speaker 2:They they do have a caseload. They could be assigned to a particular floor or physician.
Speaker 1:Got it. Okay. So that case manager is in charge of this step because they're the liaison to helping our family member take the next step.
Speaker 2:And I really wanna underscore that the case manager is not only responsible for tracking goals, but they are also responsible for patient and family education.
Speaker 1:Okay. So part of their job is patient and family
Speaker 2:Correct.
Speaker 1:Education. So, in asking questions about Margaret, if she's my mother, that's part of what they expect me to do.
Speaker 2:100%. And I feel that most families don't realize that they have that advocate. So case managers are not only working for the hospital, but they are also, disclosing options to you and educating you so that you can have agency in your choices.
Speaker 1:Got it. Well, that's super helpful. Mhmm. Okay. So what is the case manager going to start laying out for us as we consider leaving?
Speaker 2:So they're gonna talk about, goals that Margaret has met. Has she been able to stand, pivot, transfer? Has she been able to, toilet on her own? Has she been able to use a walker, a cane, all of those things? And then if it's recommended that she receives more therapies to receive full range of motion or function, that's when the case manager is going to start talking about either, skilled nursing facility, inpatient rehab, or even sometimes home health, dependent on where Margaret is.
Speaker 1:Okay, so would I assume correctly that home health is an option if she's, that's the furthest along progression?
Speaker 2:Exactly right.
Speaker 1:And if she's not progressed far enough, then they'll recommend a rehab facility of some sort. Correct. Okay. Alright. Great.
Speaker 1:Well, then you just used two other terms, skilled nursing and inpatient rehab. Can you unpack those two?
Speaker 2:So I do wanna say that the skilled nursing facility acronym trips people up sometimes because it sounds like nursing facility equals nursing home.
Speaker 1:Oh, good point.
Speaker 2:Not the case. In in this scenario, it's a level of care that's provided, dependent on Margaret's tolerances to therapies. Now, in some skilled nursing facilities, there are longer term patients, And you can do both under a skilled nursing license.
Speaker 1:Okay.
Speaker 2:But for Margaret's purposes, she may be there because she can tolerate a certain level of therapy. Not Okay. Sick enough to be in the hospital, but able to rehab, within a certain parameter of therapies per day.
Speaker 1:Okay. And then the other term you used was inpatient rehab. Is that different similar to skilled nursing?
Speaker 2:Yeah. The level of therapy that's delivered in inpatient rehab is more intensive. So, some of the goals here in North Carolina are, three hours per day of therapies, physical therapy, occupational therapy, sometimes speech therapy, but for Margaret's purposes, she's dealing with a hip fracture, so she's not likely to receive speech therapy. That can equal, fifteen hours over a seven day period, and Margaret has to qualify for that level of intensive therapy. So, part of the case manager's role before Margaret leaves the hospital is that, the case manager is going to tell you which of these two rehab options Margaret qualifies for.
Speaker 1:Gotcha, gotcha. Let me ask you this then, if we do not want Margaret to go into a rehab facility, is it our call if she wants to go home? Have the jurisdiction, the agency to say, No, thank you, we're going home, or is that not one of our decisions?
Speaker 2:You certainly do. So, the patient has the right to do things that are not clinically advisable because they are their own they're responsible for their own health care and they're their own advocate. That said, the case manager is gonna guide you towards what's clinically recommended.
Speaker 1:Gotcha. Great. Great. Okay, so to recap what you just said, home health option is if you're the furthest along.
Speaker 2:Correct.
Speaker 1:And then the next furthest along would be the inpatient rehab because you are capable of handling a higher number of hours per week of therapy. And then the next level would be the skilled nursing. Is that That's the right. All right. So you have those in order and they tell you which of those buckets you should go to.
Speaker 2:Right.
Speaker 1:Skilled nursing or inpatient, we'll focus on the rehab at this point. Do they just tell you to go and you go start Googling or what's the next step? How do you
Speaker 2:Well, again, you look to your case manager advocate. So, they likely have a pre populated list of rehabs and skilled nursing facilities and inpatient rehabs that, you know, in the triangle. So, they're going to give you that list, they're going to let you know which of those have beds available to receive you.
Speaker 1:Okay.
Speaker 2:And, they're going to highlight for you which of those options you qualify for. Okay. So it's a paper list. They're gonna hand you and they're gonna say, these, particular facilities have open beds now. Here you go.
Speaker 1:Great. So again, we're in the Triangle area of North Carolina. We're talking in the hospital and they hand us a list. Are they handing us a list of 20 options for skilled nursing and 20 options for inpatient? Or is there like two or what what's what are we looking at?
Speaker 2:Again, the criteria is beds available now. So that's gonna be a very limited number. It's usually between three and five that have beds available. And then it is it is, on the patient and their family advocate to understand what they're receiving at that facility. So there's a little bit of due diligence work required from the patient and the family advocate.
Speaker 1:Okay. You're using a term family advocate. What do you mean there?
Speaker 2:So if we have preplanned and the sibling that is with Margaret most often is going to be, say, a key supporter, and and hopefully has health care power of attorney, you want that person helping Margaret guide her choice about which next facility to choose to receive therapies in.
Speaker 1:Okay. So, you're used to the term of family advocate usually as a family member.
Speaker 2:Correct. Yeah.
Speaker 1:Okay. Gotcha. All right. So, they receive a list. There's two to five options on each of those rehab facility lists, how do they go about researching?
Speaker 1:Like how do they figure out what are the best options?
Speaker 2:This is such a great question. And this is where people really just lean into friends typically. And I wanna say lean into your experts. So again, within the hospital, you know, context, you've got your case manager who is seeing you regularly and you have access to by email. So go ahead and utilize that email inbox to ask all of your questions, but then you also have discharge planning nurses on the floor.
Speaker 2:You might even have a nurse navigator. Lean into those experts because remember, part of the required criteria for discharge is patient and family education, and you really want to gain as much understanding as you can from the expert about what is available and which is better. Remember, these are people who have, families of their own who care. You can ask the question, if this were your mom, where would you send them?
Speaker 1:And are they allowed to give you the answer to that?
Speaker 2:So that technically, the answer is no. Uh-huh. They have to give you reasonable options, and they also have to give you options with beds available now. So but the human question is, where would you send your mom given these options? And so they're likely going to highlight for you know, geographic proximity to the family member, next of kin, or they're gonna tell you, you know, I've had a lot of, patients return to me and tell me that they liked this specific rehab for these reasons.
Speaker 1:Gotcha. So they may be able to help help you without steering you too too
Speaker 2:far Absolutely. Down That's right.
Speaker 1:Okay. How much can we trust Google on this discussion?
Speaker 2:I mean, you do wanna go to Google. I wouldn't base your choice on Google reviews. People tend to post what's wrong, not not what's right. So, but you can get a sense of how people are being treated in these facilities. It certainly is a starting point.
Speaker 1:Okay. Great. Good to know. Alright. So let's get into the research itself.
Speaker 1:When we're thinking about choosing the best rehab facility, we're using the word best for our situation Mhmm. What are we looking for? What is best? What does good look like in terms of these these places?
Speaker 2:There's lots of criteria. So first, you are looking at proximity to family members because part of a component is the family member is gonna want to advocate. But also you wanna understand how many hours of therapy is Margaret gonna receive per day and who is guiding that. So ask about staff ratios, ask about are these, therapists employed by the facility that they are serving in or are they third party contractors? Ask about physician presence and how often is a physician rounding and reviewing care plans.
Speaker 1:Gotcha. Gotcha. And do you have any sort of stats or recommendations as far as things that you're listing off? Like what is good as far as physicians rounding, or doing their rounds in these places?
Speaker 2:It varies dependent on license type, but certainly staff ratios, the lower the numbers, the better, one to three, something like that is is preferable. You also just want to know, are these contractors? Contractors who rotate from facility to facility may not have the same level of buy in as staff who are permanently employed there.
Speaker 1:Gotcha. Yeah, that certainly makes sense. Okay. There's a lot to consider there when you're talking about a loved one. How much time do we have from this meeting where they're laying out and giving us this list to we have to sign up for a place?
Speaker 2:You should be given at least twenty four hours notice before discharge. Most hospitals try a more benevolent approach and give you a family care plan meeting on a Tuesday and discharge on a Friday. What you should take away is there might not be a lot of time, between the time that you're told you will be discharging and the actual discharge. So, again, you wanna lean in to the people who are available to you on-site at the hospital, but then you also do want to do some due diligence. You will go to Google, but I advise going to visit rehab facilities in person if possible.
Speaker 1:Gotcha, gotcha. So it's not that we have thirty minutes.
Speaker 2:Correct.
Speaker 1:We have some time. Enough time to stop, think, consult one another, etcetera. Which leads me to my next question. Margaret, she's in this hospital bed, family's gathered around, all these doctors, case manager, everybody's talking about her. Right.
Speaker 1:What is your recommendation from a relational perspective or a family perspective on her role in these decisions?
Speaker 2:Also a great question. So, at time of discharge, people are moving a little faster. Maybe clinicians are speaking to the family member and not to Margaret. But always hold, all of the communication, always keep the conversation flowing in the direction of Margaret because it's Margaret that all of these therapies and clinicians are guiding for. And so as a family advocate, I would say, allow time to process with Margaret what she thinks she can sustain.
Speaker 2:If an inpatient rehab is an option for Margaret, maybe share with her that what this means is that you're gonna have a little more rigor in your therapies. You're gonna have to have therapy applied at least three hours per day, you're going to have to work a little harder. What's your sense about if you can sustain that? The clinicians think you can do it, do you think you can do it? What's your preference?
Speaker 2:Always keep that at the center.
Speaker 1:That's great. Because I assume that we would want Margaret to be willing, if not even excited about opportunity to push herself or go into these therapies. Because if she's not interested, then that's going to be a little bit harder.
Speaker 2:For sure. She may not be excited about the therapies, but she certainly needs to know that there is benefit towards a rigorous therapies schedule.
Speaker 1:Great. Okay. So everybody's decided, we've had discussions, we've had a little bit of time to think, and made a recommendation, and then gotten Margaret transferred over to a rehab facility.
Speaker 2:Right.
Speaker 1:So, we're in this place. What do we do next? As the family coming alongside Margaret, what does hour one, day one look like once we get started?
Speaker 2:So, it's a reorientation for everyone. So, both Margaret and family members are gonna have to get introduced to the lay of the land, who is serving you. It looks and feels like a hospital environment, but it is a rehab environment. So, now where, nurses and doctors have been guiding care plans and the touches throughout the day, you're gonna be, met with physical therapists, occupational therapists, and those are the people that family advocates really want to connect with, get to know, and establish communication with.
Speaker 1:Gotcha. So get to know the people is the first recommendation. Before we move past that, will you break down physical therapy versus occupational therapy for us?
Speaker 2:Sure. Very, very high level. So physical therapists are master's level instructors on, and they're delivering therapies that relate to range of motion and function physically. Occupational therapists are master's level and higher in, guiding how someone transfers and navigates through the home, you may be thinking, what exactly is a transfer?
Speaker 1:Exactly, yes. That's a new term.
Speaker 2:Okay, so transfer is how someone physically moves from say standing to sitting in a car or, transferring from standing to toilet or, into out of a shower, any any of those, weight transfer bearing weight on one foot and then the other or how you transfer with the help of arm movements.
Speaker 1:Gotcha. So, and that you're saying that's an important metric or important evaluative tool for Absolutely. These therapists to
Speaker 2:Yes.
Speaker 1:Great. Okay. So getting to know the people in the rehab facility, what else do we need to think about for Margaret as her advocates, as her family while she's there for well, first of all, maybe tell us how long people stay in in these facilities. But as she's there, what are we what else are we doing?
Speaker 2:So it needs to be understood that the rehab stay is not a set of days on the calendar. It really is a progression toward goals. So if Margaret is making gains with her therapies, the rehab stay could be shorter. If she's not, it may be longer. This is all based on clinical assessments that are happening while she's receiving therapies.
Speaker 2:Most families want me to say, she'll be there two weeks or a month or, you know, give a definite timeline. Some of this is dictated also by, insurances.
Speaker 1:Great.
Speaker 2:We won't get to that today, but it's certainly a factor.
Speaker 1:Yes. Okay, yeah, let's table that for a later episode, the insurance side, and come back to just ballparking this for me. I know you don't necessarily want this question, but when people are coming out of hospital, they've broken their hip, they're 78 years old like Margaret is, is it normally like a three day, normally a twenty day, normally a six month? What are we looking at?
Speaker 2:Typically stays are twenty one days or less, and that's largely because of the insurance structure. Okay. But what you should take away is that the stay is dependent on meeting goals and whether Margaret progresses or plateaus.
Speaker 1:Okay. So it's kind of measured more in weeks, not days or months, but somewhere in the couple of weeks, two, three weeks or so. Okay. Well, we can come back to that when we talk insurance. All right.
Speaker 1:Well, how do we, as a family, know how she's progressing? Like, do I just call the doctor every day? What what's my rhythm?
Speaker 2:Well, certainly, as a family advocate, you wanna be present. That is largely dependent on, you know, family support system and how you as a family organize yourselves around visiting and engaging with staff. You can expect that your clinical team is gonna update you with Margaret's goals. And they do that in a very formalized way. So there's a care plan meeting, and it happens, it's dependent on the facility, but typically once per week, they have a care plan team rounding.
Speaker 2:So that means any staff that are touching Margaret's therapies come together and talk about her progress. Then as part of the patient family advocacy and education, understanding, there are care plan meetings that family members are invited to, and it is highly advisable that family members attend and organize themselves around those meetings.
Speaker 1:Okay. Great. So is that a term that's is this a national term, care
Speaker 2:plan It's widely understood term in the rehab realm, family care plan meetings or care goals, meeting.
Speaker 1:Okay. So the recommendation would be simply ask the facility what the rhythm is for meetings and then what they call them
Speaker 2:and ask
Speaker 1:for the invite or make sure that you have it.
Speaker 2:Absolutely.
Speaker 1:Okay. So, because you said in the hospital, it's their job to educate the family. I assume that's the same thing in a rehab facility.
Speaker 2:And you can expect that across healthcare, even with your primary physician, there is a level of patient education that's required. So, do not feel like you are being rude or demanding when you're asking for these updates. Got it. It's part of the plan.
Speaker 1:So you're asking good questions, you're showing up at least once a week at these meetings, you're paying attention to all the other pieces. Is there anything else you're looking for as far as success or support that you need to be giving?
Speaker 2:You just wanna stay in step with your care team and keep that conversation flowing. So, when you can't be present physically, because we know that life happens and you can't be boots on the ground present, you can certainly be present in your care team's inbox.
Speaker 1:Okay.
Speaker 2:Keep those conversations flowing.
Speaker 1:Great, great. Okay, our time is wrapping up here for today. Maybe give me one more thought about great advocacy as your loved one is in the rehab. Any other nuggets you would have on pushing back or being an advocate for Margaret?
Speaker 2:Yeah, as always, keep Margaret at the center of, the conversation. Her care should be person driven. Margaret is unique, and she should be included in the conversation, and family members should defer to Margaret as much as possible about what she feels is the best next step. You can appeal almost any decision within a healthcare system. So if you feel that it is unsafe or Margaret doesn't feel confident in the next steps, you can then say, we would like to press the pause button and look at all of our options before moving on to what's next.
Speaker 2:You can even appeal a discharge.
Speaker 1:Okay, that's where I was going and wondering if the doctor or the nurses or therapists say it's time for Margaret to go home and you and or Margaret feel that, woah, we're not ready for that yet. Can you push back on that?
Speaker 2:You certainly can. Know that there may be some financial implications around that appeal, but you should let your concerns be made known so that your care team can guide you, specifically around your needs, wants, goals.
Speaker 1:Perfect. Okay. So what I'm hearing is we can be and we do have a voice we should be willing to raise our hand, ask questions, give some opinions, push back as needed on the coverage. Of course, we are working ideally with professionals. We should be understanding of them as well So in this we're thankful for them.
Speaker 1:Okay, well let's pause there. Margaret's family has made their decision. She's going to a skilled nursing facility. They know how to show up for her at rehab, thanks to you. And they have a sense of what the stay will look like, when the meetings are, how to get ahold of the doctors and therapists, etcetera.
Speaker 1:But here's the catch, as they settle in, the bills start arriving. Yeah. Now we're starting to think about the hospital bills and the rehab conversations, the bills and the costs and all of that, and we start to ask ourselves a lot more questions about Medicare. So I'm just going to leave us with that, Let's pick up with a Medicare conversation about the role of that and then the other costs associated with all of this in coming episodes. For now though, we'll pause, we'll pull back the curtain on Medicare later on, and that's our conversation for today.
Speaker 1:Okay. So Rebecca, thank you for sharing your wisdom with us. Our hope is that you are all walking away a little more equipped and maybe even a little more hopeful than when we started. Wherever you are in this journey, call us at any point. We're here to help.
Speaker 1:Thanks for joining us, and we'll see you next time on the Senior Hub Podcast.
Speaker 2:Thanks all.