I just got the dreaded list of nursing homes from

When President Biden exhorted people to “stand up for seniors” during his State of the Union address, I was laying down. I was exhausted from a day of standing up for my senior—my mother—trying to advocate for a longer hospital stay while she recovers from multiple surgeries and other complications. 

The day before, I was handed the dreaded nursing home list. Every hospital has one of these contact sheets of skilled nursing facilities that they give to families when they want to discharge a patient who is deemed not sick enough to stay in the hospital, but is not well enough to go home. 

We knew it was coming because we went through it with my dad years ago. But most people aren’t expecting the step-down-facility talk to come so soon because they are under the impression that Medicare covers hospital stays—full stop. 

Technically, Medicare pays up to 90 days of inpatient care, which resets if you have 60 days between incidents, and you have 60 lifetime reserve days. That seems like a lot, and should be enough for most people. However, it all has to be justified by doctors and often works out to much less time in reality. Your advocates don’t get clued into the nuances of discharge policies until they are standing in the hallway talking to a case manager who hands them the list and tells them to pick one. 

“It’s always going to be too soon; it doesn’t matter when it is,” says Joy Loverde, an eldercare expert and author of “Who Will Take Care of Me When I’m Old?” She actually suggests asking for the discharge list as soon as you begin your hospital stay and ask all along—sometimes twice a day—what the projected timeline is for the stay. 

Another reality check hits when the patient arrives at the skilled nursing facility and you realize there’s a countdown clock on that stay, too. Medicare covers up to 100 days in a skilled nursing care facility, but, again, only what’s deemed medically necessary. The case worker is likely to come looking for you as soon as two weeks, or up to 20 days, and want another discharge decision from you. That’s mostly because after 20 days, Medicare will start charging a $200 copay per day. If a Medicare patient has secondary coverage, such as a Medicare Advantage plan or Medigap policy, that might pick up the cost of the remaining 80 days of promised coverage, but it does not mean the doctors at the facility will authorize you to stay that long. 

Here’s some of what I’ve learned from going through this process. 

1. Say no — nicely

I was waiting in the security line to visit my mom the other day and the chief medical officer of the hospital was in the lobby to greet people—the first time I’d ever seen that, so it was a nice touch. He asked me how I was doing and I said, “They want to discharge my mom before she’s ready, so I’m kind of pissed.” He said, “Talk to the medical team, I’m sure they will do what’s right for her.” 

Will they, though? 

Pardon my cynicism, but like most people in this situation, I’m tired, stressed and scared. It’s easy to respond out of that panic and try to force things to go your way. Simple, quiet defiance might be more effective. My mom, for instance, is not going to walk out on her own, and they’re not going to strap her to a gurney and send her on her way. Patients have the right to refuse discharge if they think it’s unsafe. 

Loverde says it’s important to have the number from the Medicare disclosure form you’re given at admission that has a designated “quick appeal” contact. You can also ask to speak to the hospital’s patient representative. If you need to take things further, you can pay out-of-pocket to hire an independent patient advocate. Costs vary, but most charge by the hour, and you can check with your human resources department to see if your employer provides this for you. 

You can’t hold off the process forever, but you can buy some time going through a re-evaluation and working your way up the chain of command. Be mindful that you may eventually be on the hook for charges you weren’t expecting, which is another reason to stay in good communication with the facility. 

A family friend, who is the proverbial squeaky wheel, told me he fought his mom’s discharge at the same hospital all the way up to the CEO by just methodically escalating his requests. It bought them a week, which was enough time for her medical situation to change and for them to feel comfortable about their decisions.  

2. Shop the facilities

Not all Medicare-approved skilled nursing facilities are equal, and there could be some options available to you that aren’t on the official hospital list you’re given. Check reviews online with a simple search, and ask around at the hospital or if you know people locally. If you want to dig further, you can check with state websites for violations and complaints

If you can, have somebody go check out the facilities in person. I’ve now done this in three different states, both before and after Covid. While it’s not a fun process, it really helps. There’s so much you can tell about a place when you walk in the door. Don’t be charmed by fancy lobbies or nice administrative offices. Make sure you see a room and a regular floor. Trust your smell test. Do the nurses look harried? Do the patients look drugged into a stupor? Would you feel comfortable staying there yourself? 

Remember that you have a choice in this process and don’t have to go anywhere you don’t want to go. But also be aware that the facility has to accept the patient, too. 

3. Keep an eye on things once transferred

The inspection process doesn’t stop once the patient moves to a new facility. You can tell a lot on a visit, but you can’t know things like how long it takes for nurses to respond to a call button. Staffing on any given day could be variable, and you never know when a run of illness is going to take hold, not just Covid, but also flu and other communicable diseases. Maybe the patient just doesn’t like the food. 

You’ll want somebody to stop by and check on things, unannounced, especially if the patient is not mobile or cognizant. A friend of mine once hopped on a cross-country flight at the last minute because her mother mentioned that she was waiting a long time for an aide in her care facility to come help her to the bathroom. The place was nice, and there were no red flags that would have warned the family of anything amiss. But the idea that her mother was uncomfortable was just too much guilt to bear, and so my friend went to see what she could do to make sure that wouldn’t happen again. She talked to the staff and her mom and worked out a plan for bathroom visits.

In the State of the Union speech, Biden was talking about shoring up the Social Security trust fund and securing Medicare and Medicaid funding. Those are the big things that the government needs to do. It’s the little things that families get left to handle, because every care situation is different. One thing is the same, though, in that all along the way, somebody is going to have to stand up for loved ones and advocate for them to get the care they need. 

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