My mother lives in so. FL. She is a brittle diabetic, has temperal
arteritis, hypertension and has been on high doses of prednisone for
ten months -- with all attendant side affects. She suffers full blown
diabetic neuropathy in both legs and feet and diabetic retinopathy for
which she received several sessions of unsuccessful laser surgery and
which the temperal arteritis and prednisone have exacerbated. She is
blind and bed ridden, but still can bathe herself and feed herself. I
am out of state and come down once a month to take care of paperwork,
and all else she can no longer handle. In addition, I am on disability
and my health is sometimes precarious. Mother's home health service
wants to cut her off nursing visits when I am in FL. This is
apparently a business decision -- not a health decision. What recourse
do I have through Medicare?

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Request for Question Clarification by websearcher-ga on 30 Jan 2003 07:06 PST

Hello cintn:

I sympathise for your obviously difficult situation regarding your
mother's health concerns. I've been able to find some information
about what a "home health agency" (HHA) is required to do under
medicare w.r.t. nursing care, but I need a few more details about your
mother's situation before I can interpret the results (or move on to
find more information).

* Does the HHA visit your mother every day? If not, how frequently?

* What are the total hours they spend with your mother each week?

* Is it a nurse who visits or a home health aide (or both)?

* Has your mother's health situation changed since the HHA made the
decision to cut off visits while you are there?

* Has the HHA gotten a doctor's approval for this "change of plan of
care"?

The answers to the above questions might help us determine what
recourse we have through Medicare.

Thank you. 

websearcher-ga

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Clarification of Question by cintn-ga on 31 Jan 2003 03:05 PST

* An LPN visits my mother twice a day -- 8 a.m. and 4 p.m. -- her
sugar readings fluctuate sometimes wildly from morning to evening
(e.g., 91 and 320)--endocrinologist receives readings weekly and makes
frequent changes in morning or evening amounts of both types of
insulin.

* The amount of time they spend with my mother depends on her
condition when they arrive -- both physical and mental -- she is
suffering from prednisone psychosis and depressions.  She looks
forward to the nurse visits as we have lucked out with a couple of
compassionate nurses who like her and go the extra mile.

* Just LPN's visit mother -- no aides. She has a woman who has cleaned
for her for a time and she makes it her business to stop in to wash
the few dishes and make mom's bed.  But, as I stressed to the two
women making the home visit, Teresa (housekeeper) IS NOT A CARETAKER,
which they grabbed onto and started investigating her ability to be
one.  She is a Polish immigrant whose English is sketchy and she is
unable and unwilling to be involved in the medical side of mom's care.
 She does these things because she is kind and likes my mother.

* My mother's condition continues to deteriorate -- even since the
visit.  Keep in mind, they neither looked at the nurses' file, nor had
any knowledge of her medical condition.  My understanding from one of
the nurses is that they are "dumping diabetics" because the amount of
money paid by Medicare for the visits has dropped. The irony is that
on the bottom of their business cards, they list themselves as a "not
for profit" organization.

---

Clarification of Question by cintn-ga on 31 Jan 2003 03:20 PST

* I am quite sure that my mother's PCP has not been apprised of the
"change in plan of care". Originally when my mother was released from
hospital and home care was arranged, Dr. Homer (my mother's PCP for
the past 15 years) warned me that in So. FL, finding a "good" HHA is a
crap shoot -- others can be much worse and to keep that in mind if I
find small things unsatisfactory. I am being cautious in fussing with
them, as my feeling was that they were looking at the "bottom line"
rather the patient's needs. This is something I want to avoid. My
mother has become very fond of the nurses and, in addition, any
changes to her routine or life in general at this time traumatizes
her.

Thank you for your help.

Hi cintn:

Thank you for your detailed clarifications. They should go a long way
to helping me help you.

Given my experience at Google Answers, it is apparent to me that
helping you is going to be more of a dialogue than a straight-up,
one-time answer. This is fine - I am happy to work through this with
you until we solve the problem or determine that nothing more can be
done. Please be patient; the process may take a few more iterations.

Thank you for letting me know that you have concerns about alienating
your mother's HHA - that has great bearing on how you should proceed.
Do you think that if you get "tough" with the HHA administrators, that
it will affect the (attitude or identity of the) nurses that come to
treat your mother? Sounds to me like the nurses themselves are doing a
great job and that your disagreement is strictly with the
administrators.

Before we get into specific strategies to try, I think we should look
at the most important piece of evidence/facts/data that I have been
able to find regarding your mother's situation.

Please read through the document "Medicare and Home Health Care" that
I found at the official Medicare sight:

http://www.medicare.gov/Publications/Pubs/Pdf/hh.pdf

My interpretation of this document (in regards to your specific case)
is as follows. I won't bother with the points that your mother
obviously qualifies for (e.g., homebound, non-full time care, etc) -
instead I'll focus on what I think might be the advantageous (or
possibly contentious) points.

* Your mother obviously has a doctor-approved "plan of care", and the
fact that she has had the same doctor since that plan was originally
put into place bodes well. Have you spoken to your mother's doctor
about the change in direction by the HHA? Given that your mother's
state is deteriorating, I can hardly think he/she would be OK with
this lessening of care. That might be a good place to start.

Supporting Quotes: 

"You will continue to get home health care as long as you are eligible
and your doctor says you need it." (Page 4)

"Only your doctor can change your plan of care. Your home health
agency cannot change your plan of care without getting your doctor's
approval. You must be told of any changes in your plan of care." (Page
5)

* The services that your mother receives certainly seem to me best to
be done by a skilled nurse. You are not a skilled nurse, correct?
Declining to help your mother while you are in town certainly seems to
me like they are making a (potentially dangerous) change in her plan
of care.

Supporting Quotes:

"Your home health agency must provide you with all the home care you
need, both staff and medical supplies." (Page 12)

"Skilled Nursing Care: A level of care that must be given or
supervised by licensed nurses and is under the general direction of a
doctor. All of your needs are taken care of with this type of service,
including giving direct services. Examples of skilled nursing care
are: getting intravenous injections,..." (Page 19)

* One area where there might be some "wiggle room" for the HHA is the
fact that your mother needs visits *each day*. I'm not sure from this
document whether your mother is covered for daily visits.

Supporting Quotes: 

" You must need at least one of the following: intermittent (and not
full time) skilled nursing care,..." (Page 3)

"To decide whether or not you are eligible for home health care,
Medicare defines “intermittent” as: Skilled nursing care that is
needed or given on fewer than seven days each week or less than eight
hours each day over a period of 21 days (or less)." (Page 5) This
seems to exclude your mother.

"Once you are getting home health care, Medicare uses the following
definition of part-time or intermittent to make decisions about your
coverage:
Skilled nursing or home health aide services combined to total less
than 8 hours per day and 28 or fewer hours each week." (Page 8) This
seems to say that your mother is eligible - assuming she doesn't get
care for more than 28 hours/week.


There is more to this document, but the above are the most important
points, I think. In my reading of it, they have no grounds to "dump"
your mother just because she is a diabetic and doesn't generate the
amount of revenue they'd like.

Question: Are you already paying for some of your mother's care (above
and beyond Medicare? If so, what are the details?

So, now that we've seen some facts, what to do about the situation?

1. Talk to Dr. Homer about the situation. Make sure that he/she knows
that you don't want to switch HHAs nor do you want to "turn" this one
against you. Perhaps you can have him/her on board to back you up if
and when you need it.
 
2. Approach your HHA administrator about this situation. But first,
lead with the positive (truthful) aspects of your relationship with
them. How when you first needed a HHA that your doctor said it was
hard to get a good one and you've been so lucky to have these
professionals in your mother's life. How your mother really likes the
consistency and level of care and caring that she gets from the nurses
that visit - and how she's formed a bond with them all. Butter them up
- but in a truthful way.

Then you can tell them (in a non-confrontational sort of way) that
you've been reading through some Medicare documents and you're not
sure how to interpret some things - maybe they could help you.
(Playing "dumb" often works to keep people's defenses down.) Lead into
the issue of how they want to change your mother's plan of care and
whether that can be done without the PCP's approval. Tell them that
the services that the nurses perform are beyond your comfort level and
that you'd be constantly worried that you'd do something "wrong" and
your mother's health/safety would suffer. "Given my mother's fragile
condition, shouldn't these things be done by professionals, even if
I'm around?"

If they start to bring up the issue of whether your mother is
currently getting "intermittent (and not full time)" care from them,
you could suggest a compromise, where they come in *just* to do the
medically complicated things when you're at your mother's house and
nothing else. (Assuming this is satisfactory to you.)


How is this stitting with you so far? There *are* ways that you can
appeal any decision your HHA makes about your mother's care, but I
think (given you want to preserve the relationship) that that is for
another day.

Please let me know what you think.

Thanks, 

websearcher-ga 


Search Strategy: 

medicare
://www.google.ca/search?hl=en&ie=ISO-8859-1&q=medicare&meta=

nursing visits
://www.google.ca/search?hl=en&ie=ISO-8859-1&q=nursing+visits&meta=

---

Request for Answer Clarification by cintn-ga on 01 Feb 2003 06:09 PST

I didn't know where else to address some of the issues and questions
you brought up in your very thorough answer. It is very comforting to
be able to dialogue with a real person instead of reading and trying
to interpret the myriad Medicare publications.

Yes, I have to involve Dr. Homer both as her physician who (as far as
I know) has no knowledge in the changes proposed by the HHA. They have
certified my mother only through March. I will call him when I return
to FL this month. In addition, he is on the board of this particular
HHA.

No, I'm not a skilled nurse. I have deteriorating osteo arthritis in
both hands (thumbs) and less than perfect eye sight myself.

The "wiggle room" you mentioned shouldn't be an issue because my
mother is for all pratical purposes blind and her sight is
deteriorating due to the diabetes and the prednisone.

There appear to be some contradictions in the Medicare publication. At
any rate, the time she requires is far less than 28 hours per week.
The nurses visit twice a day, check her blood sugar, refer to the
updated sliding scale and amount of the two different insulins she
requires and inject her. Making the injection  process more complex is
the fact that there are two different insulins used in differing
amounts in the same syringe.  All in all, less chat time (which mom
enjoys), the visits take no more than 10 minutes (unless her sugar is
too low at which point they have to give glucose and orange juice to
get her to the point where they can administer the insulin) twice a
day, seven days a week.

The only other person that takes care of the household needs when I'm
away is my mother's housekeeper, who, prior to mom's illness, came to
clean every other Friday. Teresa checks groceries and shops when
needed; washes her couple of breakfast dishes; does laundry once a
week; makes mom's bed; picks up mom's mail and takes the garbage out.
She is paid $100+/week -- outlays not included. She also picks up
medications if needed. That is definitely the extent of Teresa's
abilities. She also provides mom with some company because she is
alone.

As to the "buttering up" -- I preemptively buttered the home visitors
up by lauding the service and nurses. When I was told the reason for
the visit and the decisions made and contemplated, I called the
Director of Family and Patient Relations and was very careful not to
antagonize, but let her know my fear, frustration and concern.

Hope that helps narrow the parameters of the information.  Thanks.

---

Clarification of Answer by websearcher-ga on 01 Feb 2003 12:35 PST

Hello cintn:

Thanks for your further clarifications. They helped shed a lot of
light. And you put them in exactly the right place - so please
continue to correspond with me in that manner.

I am glad that my dialoguing with you has given comfort. I am also
finding your (and your mother's) dilemma compelling - I'd like to
continue to do whatever I can for you.

Given the additional details about your mother's health, her specific
medical needs, the amount and type of care that she currently
receives, and *your own* health concerns - I truly believe that your
mother's HHA don't have a leg to stand on (under the current Medicare
regulations).

I think you need to direct the discussion of this situation with them
away from the financial and into the medical and ASAP, before
something potentially dangerous happens. In my humble opinion, the
fact that your mother needs a complex measurement (based on daily
fluctuating readings) of two different medications injected in a
single syringe, combined with the fact that your eyesight is not good
(for making readings/measurements) and you have arthritis in your
thumbs (which would be used in giving injections), makes you unsuited
for administering the care you mother needs. Unfortunately, it sounds
to me like an accident waiting to happen.

So, how do you get them to see the light? 

My first thought would be to contact Dr. Homer and fill him in on the
situation. The trick will be to do so in a way that he won't go
"ballistic" on the HHA and affect the relationship the nurses have
with your mother. The fact that he sits on their board could be
advantageous. Given that he is a board member (I serve on our local
library board) means that he likely will have to discuss the matter
directly with the CEO (or whatever title the head of the company is)
of the HHA. Hopefully he can steer the issue into a "no-fault"
situation where the administration didn't understand the particular
neds of your mother's situation - no harm, no foul. Can you contact
Dr. Homer before you head back to Florida - possibly this could be
cleared up before your next visit?

If this avenue doesn't pan out (for whatever reason), the next thing I
would suggest is presenting the HHA with the very real specter of
their liability. My wife and I have been through two separate
"situations" in the last few years where we butted heads with a
neighboring non-profit and our City Hall - both of whom were doing
things that put others (not necessarily us) in danger. All the logic,
reasoning, and regulations in the world didn't budge either of them
(not that we didn't try!). However, the moment we pointed out to them
that to continue following their present paths would put them at risk
of tremendous liability - they almost immediately changed their tunes.
It was like a miracle.

However, we *did not* threaten them with this liability, we merely
asked innocent questions like "If you do that and something goes
wrong, who would be liable?" or "If there was an unfortunate accident,
whose insurance would cover that?" With your case, by this time they
obviously well aware of your conviction that you are not qualified to
give your mother the type of treatment she needs - so you could say
something like: "I'm really uncomfortable giving my mother the
treatment she needs. If something awful were to happen while I was
treating her - would I be liable? Who would be liable? Could *someone*
be charged?" Make sure you say this to the person(s) who would be the
ones to have to "handle" any suits. Again, this is not deceptive in
any way - it is merely stating your honest concerns in a
non-threatening, yet explicit manner.

If even this doesn't work out, the next step is to contact a higher
authority. I'd suggest making a few phone calls first, to such places
as the Medicare hotline, your Centers for Medicare & Medicaid Services
Regional Office or State Health Insurance Assistance Program -
Department of Elder Affairs, both of whose phone numbers can be found
at:

Helpful Contacts - Florida
http://www.medicare.gov/contacts/Search/Results.asp?State=FL%7CFlorida&chkQuestionSelect=01%7CGeneral+Medicare+Information&submitRedirectResults=View+Results+%3E&SearchType=Standard

But let's hope it doesn't get that far...I think you have a great
chance in getting Dr. Homer to assist you. And he is aware of the fact
that you need to not alienate the HHA in the process.

Please let me know how things work out and whether you have any
further questions.

My prayers are with you both. 

websearcher-ga

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Request for Answer Clarification by cintn-ga on 02 Feb 2003 05:37 PST

I agree with you completely about contact with Dr. Homer. My family
has always dealt with these situations with humour -- I think this is
misleading Dr. Homer in a way. On our last visit, I got him alone for
a second while my mother was in the lab for blood work and tried to
let him know that her mind is deteriorating (prednisone psychosis) --
we had a second before my mother wheeled up, but I wanted to pursue
this with him. Consequently, I have reason to speak with him alone
prior to my return trip to FL on 2.13.03. I will call him on Monday.

We have had "problems" with only a couple of the nurses in this
particular HHA -- the field nurse who tortured my mother the day she
returned from hospital by plodding through requisite paperwork when an
insulin injection was much needed; and a couple of male nurses who
were unreasonably late in the afternoons and whom I understand are in
hot water already with the HHA. When the HHA was called to request
that these two men not be sent again, I sensed (which was confirmed by
the other nurses) that if we made "trouble" we would be dropped. This
attitude or the threat implied through this attitude bothered me
greatly. I called Dr. Homer after the field nurse showed no compassion
for the patient's needs and, oh so slowly, fiddled with her papers. He
said he could find mom another organization, but told me it could end
up being a worse situation rather than better. What a business!!!

I will let you know how my conversation goes with Dr. Homer when I let
him know changes to mom's care are being made without consulting him.

Thank you so much for your thorough and timely replies.

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Clarification of Answer by websearcher-ga on 02 Feb 2003 07:37 PST

Dear cintn:

My heart goes out to you. I, too, am hopeful that Dr. Homer will be
able to assist in this situation.

I look forward to hearing back from you this coming week. 

websearcher-ga