Why Transfer my Mother-In-Law from ICU to LTAC Even if She is Unstable? Help!
Published: Sat, 03/11/23
Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for
Families of critically ill patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in Intensive Care!
This is another episode of “YOUR QUESTIONS ANSWERED” and in last week’s episode I answered another question from our readers and the question was
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer questions from one of my clients Eric, as part of my 1:1 consulting and advocacy. Eric’s mother-in-law is in a step-down ICU, and he is asking why the ICU team wants to transfer his
mother-in-law from ICU to LTAC even if she is still unstable.
Patrik: Yeah, so at the moment in the stepdown ICU, what’s the nurse-to-patient ratio, 1:2?
Eric: It’s 1:4, 1:2 was CCU and then now 1:4.
Patrik: Why? Okay, that’s not great because most of the time, people go from ICU, step-down ICU from 1:2 to then LTAC, or a skilled nursing facility to 1:4, I would imagine that in a skilled nursing facility, it’s worse than 1:4.
Eric: I’m assuming because it’s 1:4 here and it would be 1:4 in the LTAC, so I’m assuming because this skilled facility is a step-down it’s going to be, I don’t know, 1:6, 1:8.
Patrik: Yeah, something like that, and probably-
Eric: And those places have horrible reviews. They’re horrible.
Patrik: Right. Oh, no question there, they’re horrible in other places too and it’s
probably a 1:10 overnight.
Eric: Wow.
Patrik: Right?
Eric: You think there’s a possibly that if we fight, she can stay in the hospital at least for another month?
Patrik: Absolutely. You should fight this tooth and nail.
Patrik: I’ll give you another scenario. Let’s just say she bounces back into ICU, there’s no guarantee what she will go back to the same hospital and same ICU depending on bed availability. I’ve seen cases, Eric, where someone goes from ICU to LTAC and the very next day, they’re bouncing back into another ICU. So, they’re basically within three days, they’re in
three different places, it’s madness.
Eric: Yeah, and let’s not forget she still has pneumonia, and she still finds it fighting a megabug like-
Patrik: Right, right.
Eric: … they say she’s stable, but I don’t think she is.
Patrik: Here is another line of argument, what specialties are involved there at the moment?
Eric: At the hospital?
Patrik: For your mother-in-law’s care, specialties like she would be under neurologist, I would think.
Eric: Right now, she’s under a neurologist, the long-term acute facility, there would be a neurologist too, but in this other nursing place, there’s no neurologist.
Patrik: Right, and given that she had a cardiac arrest, there would be a cardiologist?
Eric: I don’t know, I will look into it.
Patrik: Right. So basically, you should find out what specialist are still involved, are they actively involved, are they sitting passively on the
sidelines? If she needs active involvement from a specialist, are they needed and would they have access to those places?
Eric: Yeah, I don’t think in the nursing facility they would.
Patrik: Right.
Eric: I know the long-term that they wanted to send her, she would have a neurologist, 1:4 ratio, they have a pulmonologist inside. I mean, they can treat a lot of things, but if there’s a lot whole bunch of blood involved, they
have to send her back to the ICU. That place was better.
Patrik: Right. Of course. And the other reason I’m so opposed to these facilities as well is really that at the moment at least she’s got a team that hopefully gotten to know her and now they’re starting from scratch again.
Eric: Yeah. So, you think we should fight at the hospital by asking for the discharge policy and typically in most cases the discharge policy usually says it cannot happen without family or client’s consent, correct?
Patrik: Correct, unless, obviously, again, that there would be exceptions to the rule. The exceptions to the rule are, obviously, if someone is running out of entitlements, which hopefully you can be avoided, by her going over to the primary insurance and I guess the other exception to the rule is that if she was really well enough, but that’s not the case at the moment.
Eric: Yeah, I mean, they’re treating her like she’s stable, but she’s not.
Patrik: She’s not, she’s not.
Eric: Okay, so we’ll ask for the policy, obviously, I think there’s some money stuff involved, they probably want to kick her out because her insurance is probably running out of resources, but then you also say get the primary insurance involved as soon as possible.
Patrik: This is probably the first time that I’m hearing this the other way around. It’s usually the other way around that insurance is trying to kick them out and then someone has extra cover and keeps them where they are.
Eric: We know that
the insurance would probably give us more options, but that’s going to happen for a whole month.
Patrik: Yeah, yeah.
Eric: So if we appeal it,
because it’s a fast appeal, right, so that would take like two to three days, correct?
Patrik: Look, probably hospitals are very slow or insurance, anything that-
Eric: So do you think we should appeal it with first insurance or with the insurance company that’s denying it?
Patrik: Both. I think you should be working on potentially multiple fronts here.
Eric: Okay, and then you think we should call the insurance that can send her to LTAC and tell them what’s going on?
Eric: Okay. That’s what I’m trying to figure out. Like, I know eventually they are going to
end up kicking her out, but if they are going to do that, we really want it to be to this long-term acute facility that seems to be a little bit better.
Patrik: Yes, definitely.
Eric: But as of the moment, they’re denying it, we’ve asked two times and the insurance keeps denying it without a lot of substance as to why they’re denying it.
Patrik: And your hospital or the hospital that she’s at, they just go along with whatever the insurance is
saying, they’re not challenging that, of course not.
Eric: Yep, yeah, and know because she transferred to this new room, now she has another doctor that doesn’t care about her, so the previous doctor that we wanted to keep in CCU loved her, like she was really fighting for her, but now this doctor, he hasn’t even
walked in the room once, you know what I mean?
Patrik: That’s terrible.
Eric: Okay, so some points to mention when we are fighting
with the two insurances: distance, reviews, they may not have a neurologist, they may not have a cardiologist and stuff like that, right?
Patrik: And you would also need to look at things like some of these facilities may still have visitation restrictions because of COVID, I would look at all of that. You might feel comfortable on paper to go somewhere else and
then you find out, oh, they still have visiting restrictions because of COVID or whatever else they might come up with.
Eric: Right. But you think a strong argument is enough? Like, I feel like the doctor would be like, “Well, I’m sorry, there’s nothing I can tell you about that.”
Patrik: Okay, I tell you something, and that may not sound practical for you to begin with, if you think you can, you can, if you think you can’t, you can’t.
Eric: Right.
Patrik: A lot of it will come down to your mindset, right? And a lot of it will come down to how you see that perceived power of the hospital.
Eric: Right, so like my fiancée and I have a super strong mindset. I mean, if legally were allowed to fight, she and I would be fighting so much harder and some much differently, but next of kin sometimes has a different way of thinking, we have to navigate the situation a little bit smoothly.
Patrik: Yes. Look, you don’t want to make enemies, I get that.
Eric: Of course.
Patrik: You don’t want to make enemies, by the same token, they’re sort of pushing you into a corner now where you need to put out the weapons, so to speak, and I mean that figuratively, of course, you need to push back a little bit. I would potentially also if you think it’s not going anywhere, you may also need to write to the hospital CEO or something like that. I would probably approach this from different angles.
Patrik: It’s really a case of you putting your foot down and putting your best foot forward. There are no hard and fast rules, but most of the time, I’ll tell you what I predict. They may not want to show you the hospital policy, and that’ll probably give you the answer that you need to know. Why would they not show you the hospital policy?
Eric: And they legally have to show me that?
Patrik: Look, I am not the lawyer, I’m a clinician.
Eric: Right, right.
Patrik: Okay, what I’ve seen is that (A), they’re going to show it to you because what do they have to hide, and (B), if they’re not going to show it to you, why would they do that? You’ve probably got your answer then.
Eric: Right, and if they don’t show it to me, then how I can fight that, like if I can’t see the discharge policy?
Patrik: Yeah, yeah,
then I would absolutely escalate this to hospital CEO or general manager, whatever their title is, right?
Eric: Okay, okay.
Patrik: But look, I have not really seen, and there would be some case studies on our website, I’ve not really seen that fight. If you start fighting, they won’t push you out.
Eric: Yeah.
Patrik: The hospitals don’t want to come into fight with their patients either. Look, I’ve very rarely seen that there will be a full-blown confrontation, they will start listening to you. Most people are a pushover, they probably already know that you’re not a pushover, right? And most of the time from what I’ve seen when we advise clients to do what I’ve advised you know, you will see that the
hospital slowly will come around and will start listen to you. So, it’s not about making it bigger than it is, it’s about fighting smart, not necessarily hard but fighting smart.
Eric: Yeah, okay. So, if you think if we fight, they can leave her there?
Patrik: Yes, and if you think, “Look, they’re really not coming around,” of course, you probably have to take it up one notch, but it’s not even necessary until you found the solution that works for you. Most families have no idea what to do and that’s why it’s easier for the hospital to say, “Yep, go there, go there,” and they don’t question, right?
Eric: Right, right.
Patrik: Because they’re just so lost and it’s easy to get lost in this system.
Eric: Yep.
Patrik: So fight in the nicest possible way to begin with and if you think that’s not going to work, you might have to take it up one notch, but I think you’ve
got this in terms of you’re asking all the right questions, you’ve done
your research online, you know that she needs to go in the right environment to prevent further complications.
Eric: Absolutely. We got to give her time. It’s like you said, there’s a time to give up and that’s not right now.
Patrik: That’s not right now. And now is the time to channel the efforts in the right direction.
Eric: Yeah.
Patrik: Look, they will understand that, and they already know you’re not a pushover.
Eric: Yeah, well, they know that we are not, but everyone’s different.
Patrik: Of course.
Eric: It’s just we’re not the only people in the family.
Patrik: Right.
Eric: But we’re getting her husband a little bit more aboard with the fighting and getting her to understand it a little bit more, so-
Patrik: Yeah, look, I talk from the perspective that you are the decision maker, I talk from that perspective-
Eric: Right.
Patrik: … I can’t talk about family dynamics, I can’t comment on that, but I talk from the perspective that you are calling the shots.
Eric: Absolutely, yeah. We appreciate that and I don’t want to take more of your time, I know we’re a little bit over half an hour. I don’t know how we would have navigated this without you, I’m 100% going to buy another session and I’m so grateful for the work that you do, I know we said that before.
Patrik: Look, I appreciate that and I’m very grateful wherever I can to help people live better lives and get better outcomes.
Eric: Yeah, you’re amazing. Thank you for all you content, for all your support. We’re definitely going to buy another session and we
couldn’t have done this without you and the offers that you’ve put out into the world, so thank you.
Patrik: You’re very welcome and thank you for your kind words, I really appreciate that.
Eric: Absolutely. Thank you so much, Patrik. I don’t want to take advantage of your time, but we’ll be setting up another call soon.
Patrik: Okay, when you’re ready. All the best for now.
Eric: Oh, absolutely, thank you.
Patrik: Thank you. All the best for now. Bye.
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