It always comes as a shock to me that being likeable doesn’t solve all my problems. In my mind, being accommodating is the key to being likable. Of course, the problem with this thinking is that occasionally all that pent up accommodation and desire to be likeable comes boiling to the surface and I become enraged and irrational.
I’ve found that I can sometimes avoid this cycle by being less accommodating and clearer right up front about what I need and what I expect. But, it’s not easy.
There is no better place to avoid the likeability trap than when your parent is hospitalized. You have to be firm and relatively non-accommodating so you can head off the white-hot fury that ends up making you look like a looney and reduces your effectiveness.
The truth is that, when you are dealing with a hospital and all its attendant issues, you have to be vigilant and firm — right from the very beginning. Or, truth is, sometimes you kinda have to rock the boat and be a professional bad ass. You have to stand up to authority because, as crazy as it sounds, you cannot assume that the hospital knows what it is doing or has your parent’s best interests at heart.
Unfortunately, the quality of hospitals in this country is really mixed. And even the hospitals that are great aren’t necessarily all that good at handling care for very frail, old people.
Frankly, it’s entirely possible that, after reading this blog, you will know much more than the hospital staff about the unique issues frail, older adults face when they are hospitalized.
Ideally, during your parent’s hospitalization, advice and help would come from a geriatrician or primary care doctor who would guide you through the hospitalization. Their staff in turn would coordinate with the hospital team to make sure everyone’s on the same page. Unfortunately, that rarely happens in our healthcare system. So, it falls on you, the daughter, to do some pretty complex things that are far outside your expertise and comfort zone….all at the same time your life is on hold.
So, with this in mind, as I said in the previous blog, you want to avoid the hospital if at all possible. But, if your parent does end up there, here are the 4 things you can do to mitigate problems.
Know Your Parent’s “Status”
Even though we’ve been talking about avoiding the hospital, sometimes big medical events happen: a stroke, a massive heart attack, a broken bone. In this case, your mom or dad is whisked to the Emergency Room and then admitted as a hospital “inpatient” and that’s what is supposed to happen.
On the other hand, many frail older adults get shuttled off to the hospital Emergency Room for less clear cut reasons. Something seems “off” and the assisted living facility, nursing home, or physician on call default to the hospital.
When this happens, it may not be clear right away whether your parent’s issue warrants a hospitalization. And recently Medicare — your parent’s health insurance program — has been clamping down on hospitals for admitting people in this situation too frequently, profiting off of it and wasting taxpayer money.
So, more and more hospitals have been playing it safe and “observing” patients as “outpatients” before admitting them as “inpatients.” The good news is that the payment is lower for Medicare and usually the care is the same. And, in some cases, this option may be less expensive and overall better for the patient.
The bad news is that, often this whole process can end up being invisible to you and your parent with very serious consequences for the type of rehabilitation care he or she can receive.
This is because from Medicare’s perspective, your parent wasn’t actually admitted to the hospital (!)…and…Medicare requires at least three consecutive inpatient days for coverage of rehabilitation care in a skilled nursing facility.
Worst case scenario: No one tells you or your mom that she isn’t actually, technically “in the hospital,” she gets sent to a nursing facility for rehabilitation anyway, and then gets stuck with an unexpected bill from the nursing facility in the range of $12,000. Believe it or not, this can and does happen.
This is one of those times when it’s good to insist on knowing what’s what. You don’t want to get caught off guard by these rules because many people do. If, in your judgment (which is probably right), you think your mom will need rehabilitation care, you’ll want to talk to your doctor about the trade-offs of getting her admitted as an “inpatient” for three consecutive days.
Be Prepared to Combat Disorientation
There are a lot of scary medical things that can go wrong in a hospital. It’s always a dangerous place but especially so for very frail, old people.
In particular, the hospital setting actually seems to traumatize the brain of a frail, older person, leading to confusion that can decline into dementia that lasts long past the hospital stay. It’s worth taking just a little bit of time to prepare yourself for this.
Experts who run the Hospital Elder Life Program emphasize that patients benefit from having family members around to orient them and explain what’s going on, to bring hearing aids and glasses and other things from home that remind them of who they are.
They also tell us that it’s important to keep an eye out for even slight changes in your parent’s behavior, for when your parent isn’t making sense or seems unusually distressed. Chances are excellent that you’ll be the first person to notice and to alert the medical team. And you want to always question any attempts to sedate your parents because it’s rarely the solution and often causes more problems.
This program’s website also includes guidelines for hospital staff, which I urge you to read as well. For that matter, it’s a good idea to print things out and hand them to staff (they’ll love that – ha!). There’s a lot of research now that shows that, in the ICU where patients really suffer from disorientation — also called “delirium,” best practices include reducing use of medications that cause drowsiness, and providing consistent breaks from sedation and the ventilator.
According to these experts and others, it’s really important to get your parent up and walking, even around the room or down the hall a little bit. Just lying immobile in a hospital bed can be really harmful. They lose a lot of muscle strength even if they haven’t had a complicated surgery. Also, when they get up and walk around, they are better oriented and less likely to get confused. There are a lot of benefits from walking in the hospital and Paula Span has a great article on it here.
Anticipate Medication Screw-Ups
I had the opportunity this week to attend the national conference of geriatric care managers — now rebranded as Aging Life Care professionals. I asked several of them —
What is the number one thing they do or monitor when their clients are in the hospital?
And, they all said, “medications.” Again, wouldn’t be nice if you had some help from the medical teams involved in your parent’s care? Well, they do try, but there is a wide variety in the types and numbers of medications prescribed to older adults. When your parent is on a lot of medications — and many older adults are on 10 or more — imagine how easily and quickly things can get screwed up, even by the most well-meaning hospital staff.
This is one of those areas where you can only do what you can do…if possible, bring the medications with you to the hospital in a big bag and ask someone — a doctor or nurse — to review every medication in the patient chart and question how it relates to what mom or dad was taking at home. You want to be especially forceful about this if your mom or dad are on a lot of medications.
And, you want to repeat the process of checking and “reconciling” the medications every time your parent moves from one part of the hospital to another (e.g., upon discharge from the ICU to the regular part of the hospital). Ask questions, call the doctor, just be a general pain in the butt about this.
You are RIGHT TO BE CONCERNED. Don’t let anyone tell you otherwise.
Push Back When You Think You Are Being Pushed Out
Everyone wants to get out of the hospital as soon as possible, right?. And, there are good reasons for that as I mentioned above. But, sometimes you might need to delay the discharge, especially if the hospital seems to be pushing your parent out too soon.
Hospitals make more money the less time your mom is there so they are usually in a Big Hurry. It seems backwards, I know, but the shorter your stay, the more money hospitals make. The problem is that, what’s optimal for the hospital’s bottom line might not be optimal for your mom’s care or for smoothly transitioning home or to a rehabilitation facility.
And yet, all of a sudden, you hear: it’s time to go. Holy moly — go where? Next thing you know, you are trying to pick among dozens of skilled rehabilitation facilities or home health agencies with no real time to make the right choice.
The good news is that you can slow this train down a little by appealing to a third party called a quality improvement organization (Q.I.O.). Theoretically, the hospital is supposed to give you “An Important Message from Medicare” with the information you need to do this. But if it doesn’t, you can call [number here] and request a fast or “expedited” review, which ensures that the hospital care, including any out of pocket cost, is covered until the Q.I.O. makes a decision.
This will buy you time but you’ve got to be sure to call as soon as the hospital notifies you that you’re being discharged — you can’t delay calling past noon of the day you get notified of the discharge by the hospital. If the Q.I.O. agrees with you, Medicare will continue to cover the hospital stay for as long as medically necessary. If not, your care is covered through noon of the day after you get the decision.
What to do when the hospital won’t listen
Your recourse for a non-responsive hospital staff is limited. However, I would urge you to be on the lookout for a patient satisfaction survey that your parent will receive after the stay. Please fill that out. It affects the “value” rating of the hospital and ultimately how it is paid. We want hospitals to care more about the patient experience.
In the meantime, you can request help from the hospital ombudsman who can act on your behalf. Most hospitals have one and you should not hesitate to ask for help. You should also seek help from your primary care doctor. Hospitals want to have good relationships with doctors because the hospital depends on the doctor to refer the business.
Finally, trust your instincts and stay calm. It’s particularly hard ‘cause it’s your mom or your dad. But you handle complicated situations all the time in your life so draw on all your considerable talents and skills.
You’ve got this.