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
What is Sepsis?
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 Kaye as part of my 1:1 consulting and advocacy service! Kaye’s husband had a cardiac
bypass surgery and is on tracheostomy on ICU and is asking if there is a criteria for doctors transferring him to skilled nursing facility instead of LTACH.
My Tracheostomised Husband is in ICU. Is Skipping LTACH a Better Option?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Kaye here.”
PART 1
Eric: Yes, Patrik, yes, they’ve been putting him in a cardiac chair.
Patrik: Okay.
Kaye: Yes, at the edge of the bed. Yeah and I exercise with him every time and he starts moving slowly, but he cannot stand up. He cannot stand up, and he cannot sit on his own on the edge of the bed.
Patrik: How-
Kaye: He sits sometimes on the bench.
Patrik: How often are they doing this sitting him in a cardiac chair, sitting him on the edge of a bed?
Kaye: Two hours a day.
Patrik: Okay. That’s-
Kaye: Two hours a day.
Patrik: Okay.
Kaye: In the morning, I make exercises with him, and he starts pushing his legs against me so I can see that he is stronger today. He did very good. I’m trying to sit him on the edge of the bed maybe twice a day. Every time I go there morning and evening, I try to do that with him.
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Patrik: No, no, that’s good. That’s good. I’m pleased to hear that because that’s what they should be doing, right? I can’t tell you how many inquiries that I’m dealing with, where they’re not doing that. So from that perspective, I’m very pleased to hear they’re doing all the right things.
Kaye: Which is not going to happen at the skilled nursing.
Patrik: No, no way.
Kaye: It will not happen unless I will hire someone to do that for him.
Patrik: That’s exactly right.
Kaye: With him I mean.
Patrik: That’s why he needs to go to LTACH because that’s what they specialise in, right? Because he’s taken the step of getting off the ventilator, and now the next step for him is focusing on
mobilisation.
Kaye: Well, Patrik, can you just maybe briefly tell us, what are the key words that can be used when we have to communicate that will work with this request again? I mean what are the key words I should look for or what should I ask tomorrow at the meeting?
Patrik: Yeah, so definitely rehabilitation, right? What is their plan to rehabilitate your husband? You’re saying in the email that the doctors are confident that your husband will make a full recovery. Now, all of a sudden that seems to have changed. The question is, has it changed or is it an insurance issue? I don’t know. I can’t answer that question.
Eric: Right.
Patrik: In the email, you are saying that the doctors, his cardiac surgeon, the intensive care doctors, they all seem positive that he will make a full recovery. Now, all of a sudden, they are saying, “Oh well, he can only go on to skilled nursing.”
As you correctly pointed out, in a skilled nursing facility, he won’t get that mobilisation part. That’s the part he needs to continue.
Eric: Okay, Patrik, may I just cut in for a minute? On the skilled nursing, around here actually from everything I’ve read and what I’ve been told, is that they do rehabilitation at the skilled nursing.
Kaye: One hour a day, but that doesn’t mean they do.
Eric: They have a separate person that comes in for just rehabilitation. Now, the nursing facility is because he needs a place to stay because you can’t transport him every day. He needs to stay in skilled nursing, but they have the rehabilitation come in one hour a day, is that what you said?
Kaye: Yeah.
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Eric: Okay. We thought the way it was going to go was that it was going to be ICU, LTACH, wean off the ventilator and then onto skilled nursing for further rehabilitation.
Kaye: Right.
Patrik: Well, no, no I’ll tell you the trajectory. The trajectory normally is that patients go to LTACH to get off the ventilator if they have not been weaned off the ventilator in ICU.
Eric: Right.
Patrik: Then they should be going home. The reason I’m saying that is that when we come off this call … I’ve done an interview with a gentleman, maybe last year. I think he’s in Seattle. He’s any 81-year-old gentleman, and he was in ICU and LTACH for nearly 18 months. He fully recovered, and he is now back at home. It’s really worth listening to this interview because you get a lot of insights there in what this man went through to get back home, but he is a case where it clearly shows what’s possible.
Eric: Right.
Patrik: Right.
Eric: Go ahead.
Patrik: That’s the normal trajectory to go from ICU to LTACH, get off the ventilator, get mobile again and then ideally go home. Yes, there are cases where patients can’t make it home for whatever reason. They can’t be weaned off
the ventilator for whatever reason, and then they do sometimes end up in skilled nursing facilities. I’m not denying that, but that should never be the goal.
Eric: Right, I think they’re actually planning on him finishing his recovery and his rehabilitation in the skilled nursing, not that he’s going to be there forever.
Patrik: Okay, okay.
Eric: That’s what I think their plan is.
Patrik: Sure, sure.
Eric: Okay.
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Kaye: I don’t know what their plan is. I think the problem right now is with the insurance. This is what they claim.
Eric: The problem we have with that is that we know he’ll get much better attention and care at the LTACH facility.
Patrik: No doubt. There’s no doubt.
Eric: No doubt about that, right.
Patrik: No doubt about that.
Eric: I don’t think they’re saying he’s going to skilled nursing because he’s going to stay there forever and he’s not going to recover, I think they’re saying he doesn’t need to go to LTACH because he doesn’t need that level of care, and that he’ll be fine just going to skilled nursing and getting his rehabilitation there. Then he’ll go home once he is rehabilitated through the skilled nursing, but I think it’s going to happen a lot faster at LTACH.
Patrik: Oh, there’s no doubt. Okay, okay so now it gets to be clearer. So basically what you’re saying is they’re saying he’s good enough to skip LTACH. That’s basically what their suggesting.
Eric: That’s pretty much what they’re saying. He’s good enough to skip LTACH. He doesn’t need to go there. He can just go to the last phase of everything, and that’s-
Kaye: Because the insurance dictated it. The insurance says no.
Eric: I understand that. I understand that, but I’m sure that if the doctor strongly disagreed with that, they would strongly argue with the insurance. Would you agree or disagree?
Kaye: So are you still going to talk to the doctors and see if he needs help with the ventilator and stuff, right?
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Eric: Am I saying that?
Kaye: Patrik?
Eric: Go Patrik.
Patrik: No, no, I really do think that the more I’m obviously listening and the more insights that I get, I do believe the insurance is probably asking the question to the doctors. The question then is are the doctors advocating for your husband or are they not? I think that’s the question. If the doctors are advocating for your husband, they might say, “Yeah, he needs to go to LTACH.” I really depends on-
Kaye: May I ask a question? Can I ask for copies of all those reports they are sending to medical insurance? Can I ask for that?
Patrik: I think you have to. I think you have to.
Eric: Patrik, please finish your thoughts before she cuts in.
Kaye: I’m so sorry, yeah. I’m just-
Patrik: No, I don’t think there was anything to add. I think you have to ask those questions. There’s no point in beating around the bush. The doctors are changing their mind within 48 hours from LTACH to skilled nursing. The question is who spoke to who. Has the insurance contacted the doctors or vice versa, but I think that’s the channel of communication that’s probably happening in the background.
The other question that I wouldn’t rule out either is that there’s no bed in LTACH. I wouldn’t rule that out either.
Kaye: What?
Eric: When we were at LTACH, we visited the facility, they had quite a few beds open at the time. I find it hard to believe that they don’t have any beds. You’re right. That may be case, but-
Patrik: Um-
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Eric: Go ahead please.
Patrik: Open beds don’t necessarily mean they have the staff to serve those patients if that makes sense.
Kaye: No, they just don’t have enough people to serve them.
Patrik: That’s right. Open beds don’t necessarily mean open beds. The question is, if there is an open bed, do they have the resources to serve those beds?
Eric: Okay, that makes sense then, but here’s one good thing. Tomorrow Kaye, at 7:00 a.m., will be meeting with the cardiac surgeon. She knows exactly when he comes in. Here’s another good thing. The cardiac surgeon has given us the royal treatment. He really has a fondness for her husband and his case. He is a designer of a special mattress that prevents bed sores. He went head over heels to make sure that he got one. Anyway, Kaye will be
meeting with him tomorrow. So far as a doctor being able to advocate getting him into LTACH, I think that’s probably a good way for us to go.
Patrik: I couldn’t agree more. So at the moment, the cardiac surgeon, is he the primary care giver? Is your husband admitted under this cardiac surgeon to the hospital, do you know?
Kaye: If he’s what? If my husband’s what?
Patrik: The cardiac surgeon obviously is the person who performed the surgery.
Kaye: Yeah.
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Patrik: There’s a very good chance that the cardiac surgeon is the primary caregiver at the moment. What that means is your husband is probably admitted under the care of this cardiac surgeon. Do you know that?
Kaye: Mm-hmm (affirmative). He’s his doctor. Yeah, I’m reading his doctor here. Yeah, it’s his doctor.
Patrik: Okay, from a hospital perspective, or from a doctor’s perspective, if you will, he should be one of the primary influences of what the next steps are. He certainly is not the only one, but he should be having a big influence on whatever is going to happen next especially if you’re saying this doctor seemed to be quite fond of your husband’s situation. Do you feel like he’s looked after your husband well overall? Is that your
impression?
Eric: Yes.
Kaye: Mm-hmm (affirmative).
Eric: I think he’s gone above and beyond duty.
Patrik: Okay.
Kaye: He is.
Patrik: You have this meeting tomorrow morning at 7:00 a.m. with him. When have you last spoken to him?
Kaye: Every morning I meet with him actually for a few minutes and we always chat, yeah.
Patrik: Who delivers the message of going to skilled nursing instead of LTACH? Who delivers that message?
Kaye: The case manager. There’s a case manager here. There’s a girl who is in charge of insurance issues.
Patrik: Okay, you still don’t know who pulled the strings in the background for all of a sudden going to skilled nursing instead of LTACH. You still don’t know who was pulling the strings.
Kaye: No.
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Patrik: Okay. I do believe the cardiac surgeon might have some insight there. It may even be the case that the cardiac surgeon doesn’t even know that this is happening. The cardiac surgeon might think he’s going to LTACH. I do believe the sooner you can speak to the cardiac surgeon the better.
Kaye: Well, tomorrow morning.
Patrik: Yeah.
Eric: Right.
Patrik: I do believe-
Eric: I think what you’re eluding to is that probably he has a very strong influence on making something change and him actually going to LTACH.
Patrik: I would very much hope so. You see one thing that people forget is that the hospital, as well as the doctors, whether that’s the cardiac surgeon or if it’s the intensive care doctors, they have a duty of care, right? And then often don’t-
Kaye: Okay. It’s up them. Okay.
Patrik: Well, it’s up to them, but it’s not only up to them. You have a say. It sounds to me like you’ve been misled to a degree especially in the last 48 hours. I guess you’ve got to call them out on it and get all the reasoning. You’ve got to get the criteria. To definitely have to get the criteria in terms of what boxes does my dad need check to go to LTACH and what boxes he need to check to so skilled nursing, right?
Another question for you, have you considered home care at all?
Kaye: Home care?
Patrik: Yeah.
Eric: I looked into it. I can’t find anything in Ohio like your company provides in Australia. I cannot find anything like that here in Ohio.
Patrik: Okay, that’s fair enough. Have you-
Eric: I don’t … yeah.
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Patrik: That’s okay. I wouldn’t have thought that there is anything similar, but have you at least brought it up, and I’m not saying at this stage, the next best step for your dad is to go to LTACH. There’s no question in my mind that this is the most natural next step. However, it’s always good to keep talking to people especially with skilled nursing, you are quite hesitant and so would I be.
If your dad keeps on recovering, you might still have to look at home care down the line. It might be like a nurse coming for an hour a day, or whatever the case may be, hopefully if your dad continues to recover. It’s just something I would keep in the back of your mind if that makes sense.
Eric: No, it makes sense. The only problem is that Patrik is that our house is not very conducive to somebody that is not very mobile. We have steps. We have a main floor that you still have to go up steps to get to.
Kaye: Yeah, yeah. Otherwise, we’d do that, but with the steps, it’s not doable, yeah because of the steps. His room is upstairs.
Patrik: Okay, fair enough.
Eric: It would be very difficult to do the in home health care.
Patrik: No, no that’s fair enough. Okay, okay. Are you talking to somebody from the insurance? Are you in contact with them?
Eric: Not yet. She’s made a phone call to them, but they have not called back yet. She just made the call this afternoon.
Patrik: Okay.
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Kaye: Do not take that, do not touch that (talking in background). I’m so sorry, Patrik. I’m sorry Patrik. I’m here with my husband. He’s doing what he’s not supposed to do. Yeah.
Eric: If you haven’t noticed, we have another issue too with him in that he only speaks Russian. He doesn’t speak English.
Patrik: Okay, okay. Have you gotten an interpreter involved?
Kaye: I’m the one for that.
Patrik: You’re the one. The solution should have an interpreter.
Eric: Very important.
Patrik: The hospital should have an interpreter.
Eric: They do, her name is Kaye.
Patrik: I understand. I understand. Okay. (laughing)
Kaye: At this point right now, I probably will be getting ready to meet with the doctor tomorrow morning. I will be calling everywhere that I can to be honest with you.
Patrik: Right. I have two more questions. Have you signed anything for your husband going to LTACH or to skilled nursing? Have you signed any documents?
Kaye: No.
Patrik: No. I would be very-
Kaye: No, no.
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Patrik: I would be very hesitant in signing anything unless you are 100% behind the decision in whatever the next steps are. I would not sign anything.
Here is another quick question. Well, it’s not a quick question. It’s actually, I think, very important question. Have any discussions been made about DNR? Do you know what I mean when I refer to DNR?
Eric: I’ll answer that. No, nothing has been signed. There has been discussion. They brought it up in the very beginning, but we made it very clear that will never be an option.
Patrik: Okay, okay, good.
Kaye: What is that there?
Eric: Do not resuscitate.
Kaye: Okay, yeah, yeah Mm-hmm (affirmative).
Eric: You didn’t sign anything like that I’m pretty sure.
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Kaye: No, I don’t think so.
Patrik: The other question I think is quite important, Kaye, you are the medical power of attorney at the moment for your husband?
Kaye: Yeah I do.
Patrik: There’s nobody-
Kaye: No one else, only me. Yeah.
The 1:1 consulting session will continue in next week’s episode.
