Table of Contents
The Spouse in the Community
There is a team dynamic to a Post-Acute stay at a Nursing Home in the context of a married couple. The spouse in the community (i.e. the one who has not suffered a health decline) may have to do more of the long-term planning, coordination, and decision-making with the Nursing Home Staff due to the spouse's inability. You must also understand the concept of being a partner in care. It's always best practice to teach the staff about your spouse - likes/dislikes, routine - and do so in a way that is not overbearing for the staff.
Finances & Assets
Under Medicaid rules, spouses who remain in the community are entitled to retain certain Assets that are dually shared by marriage like a single-family home, a business, and vehicles. Likewise, Medicaid also considers living expenses for the spouse when determining what is called Patient Liability for the spouse in the Nursing Home. These financial exclusions are by design so the Medicaid system does not inadvertently impoverish a resident’s spouse, or hinder the spouse in the community from their Quality of Life.
Another reason why assets can be maintained is because, in some cases, Medicaid can be terminated if your functional status and clinical condition improve or stabilize enough where you can be moved to a separate silo of Medicaid coverage - group homes or HCBS. I’ve seen this happen to residents who have lived at my Nursing Home for over 3 years. In fact, one Medicaid Case Worker in my state admitted to me that, on an annual basis, there is an effort to review & transition up to 10% of their Nursing Home caseload to a lower level of care for cost purposes.
Medicaid refers to this as a recertification process, or a utilization review. It is completely legal, and is a foundational operating principle for Managed Care insurance companies.
The spouse remaining in the community will likely see some type of carve out of his or her spouses’ Social Security Income as Medicaid determines the Patient Liability. Because of this, it is critical that there is total cooperation and prudence given to capturing all living expenses and liabilities to turn into the Medicaid office for determination. Bottom line - the more qualifying expenses the spouse in the community can find, the less the Patient Liability will be. A lower Patient Liability means the spouse in the community can still expect to rely on some or most of his or her partners’ social security income benefits.
Care Planning and Clinical Considerations
Clinically, when you enter a Nursing Home for post-acute care there should be an initial focus on care planning and therapy goal setting. These care paths are driven by the professional therapists at the Nursing Home along with the Attending Physician orders for care. In order for your spouse to return home successfully, the overall clinical and functional condition of your spouse must have improved and the Attending Physician along with the Interdepartmental Team must deem your spouse safe to discharge.
Of course, your spouse can always leave the facility Against Medical Advice, but data shows the chances of a successful discharge home are drastically lower. A best practice is to receive education and techniques from the treating therapists and nurses to care for your spouse at home; Therapists can bill for spousal/caretaker training, so take advantage of this opportunity.
Therapists can also do what’s called a Home Evaluation in which they can review the layout of your dwelling and recommend assistive devices or recommend different ways of setting up your house (moving furniture, bedroom layout, etc.) to increase the functional capability of your spouse.
Insurance plays a major part of both planning care and the financial obligations. Though too large of a topic to discuss in one paragraph, I would suggest within the first 72 hours doing a full review with the facility Business Office Manager of all benefits options. Though these are not professional financial advisors, they will offer great insight into what can be expected financially.
At some point during your stay, you may receive what’s called a NOMNC, or a Notice of Medicare Non-Coverage. This means that for whatever reason, you no longer qualify to receive skilled benefits. If you disagree with the NOMNC, it is your right to appeal. Legally, the facility cannot discharge you nor cut off care & services that are needed. There is financial risk with this decision; if the appeal is denied you will be billed for the amount not covered. So, appeal wisely.
Important questions to consider are, if my husband or wife needs long-term care, am I financially knowledgeable of how the costs can affect my household financially? And, What’s the cost/benefit of investing in a Long-Term Care Policy? Or, how much of my income and assets are safeguarded against long-term healthcare expenditures? These are questions that should shape your financial or estate planning process.
The Spouse in the Nursing Home
Mentioned above, there is a team dynamic at play when you are recovering. Your sole responsibility is to focus on recovery and successfully discharging. This means trusting the therapists and MDs that are guiding your care. I’ve seen patients with moderate-to-high potential to get better fail to do so because of their inability to trust the team of caregivers, doctors, and therapists. You should always be the most important voice when it comes to your healthcare decisions, however at some point you have to trust in the process of post-acute care paths.
Finances & Assets
Assuming the spouse has possessed social security income and/or a retirement pension before entering a Nursing Home for short-term care, there is really no substantial effect besides the copay incurred, if at all. But for the sake of argument, let’s say when the spouse enters a Nursing Home his or her care needs have now become too much to safely return home. Unless you’ve got a substantial amount of savings unprotected, you can obtain Medicaid Coverage for Nursing Home care. Remember, Medicaid coverage for Nursing Home care requires the patient to qualify clinically and financially. Otherwise, funds must be “spent down” and the resident would have to reapply at a later date.
Care Planning & Clinical Considerations
Successful Nursing Home visits can be won and lost based on frame of mind. I can’t overstate how critical it is that the patient must make the choice to get better. I am not trying to be critical of elderly people that may have just endured a 14-day hospital stay, however I am speaking to how powerful positive thoughts & how actively engaging in your plan of care can get you back home.
When entering a Nursing Home for Post-Acute care and with the intent to return home, you can expect multiple therapy discipline sessions per day for 5-6 days per week based on your tolerance. Meanwhile, you’ll be receiving skilled nursing care and oversight by a team of licensed professionals and certified nursing assistants. In some ways, it may feel as intense or more intense than in an acute care hospital because the goals are different and therapy services are on the clock to get your functional abilities improved as quick as possible. To put it another way, a physicians’ goal may not be to send you home, but rather get you stabilized enough to receive more care at a Nursing Home, so you may not receive a ton of inpatient therapy in the hospital.
As a patient, perhaps before entering a Nursing Home, you need to consider what Nursing Homes are around you and what would be your #1, #2, and #3 pick for post-acute care. Though you cannot always trust everything you read, my suggestion would be to base your decision off of three sources of information:
Number One, look up the last 6 -12 months worth of Google Reviews for the Nursing Home. Try to sift out those from former employees and focus on the reviews about the care and therapy services - what do they tell you?
Number Two, visit Medicare.gov and search “Nursing Home Compare”. This is a nationwide star rating service that rates every nursing home nationwide based on a standardized scorecard. Here you can look up over 20 clinical and therapy outcomes called Quality Metrics. But, specifically look at their Quality Metrics. These metrics are the most updated care outcomes for the facility and, in my opinion, can give you the most relevant and objective information out there backed by Medicaid logic.Other star ratings, like Health Inspection ratings, have been frozen for some time due to a rules changem, then a subsequent COVID-19 pandemic.
And number three, go visit or have your spouse go visit. Be mindful of two things when visiting. How does the facility consistently smell? And, overall what is the inherent feeling you got when visiting? Smells can indicate foundational care concerns and/or environmental issues. Some root causes of persistent smells of urine or bowel could be inadequate staff training, a failed Quality Assurance program, high turnover, or a lack of oversight and leadership in the facility.
Next, trusting your “gut feeling” about a place is also important for your p. My gut feelings about a business come from many different observations; if I walk into a Nursing Home and I can tell staff are happy, there is attention to details like appearance of baseboards and paint,
I am confident that, together, these three sources of information will steer you to the best option or options for your post-acute care. If you’d like more information, there are plenty of credible sources for consumers to review Nursing Home performance, Medicaid programming and ways to pay for a Nursing Home stay, and also support groups for families and spouses when potentially facing a newly diagnosed disease.