Dear Rita: My 88-year-old grandmother, Francine, has been staying in a rehab center in Southern California since fracturing her pelvic bone in a fall. Medicare covered her stay for a limited period of time, but now the payment will be discontinued. Staff at the facility have stated that they don’t have any Medi-Cal beds and that they are not budgeted for a long-term resident. Our dilemma is that my grandmother cannot return home by herself because she needs ongoing assistance, but she is also low income and can’t pay for in-home services or assisted living. She needs a lot of help with everything. Her mobility has been compromised. The facility is pressuring her to leave. What can we do to keep Grandma in her current skilled nursing facility? I am far away and need her to be in a safe place. — R.M., Berkeley
Dear R.M.: It’s understandable that you want your grandmother to be in a safe and stable environment with the appropriate level of care. And you certainly need the peace of mind that this is happening.
It also sounds like you need some answers about Medi-Cal, nursing homes and your grandmother’s rights.
One of the criteria for remaining in a skilled nursing facility (SNF) is that it be medically necessary. In your grandma’s case, she’s probably not able to bear her weight and is most likely unsteady on her feet.
This means she’d be limited in her ability to complete her activities of daily living. Things like transferring from her bed to a wheelchair, or from the wheelchair to the toilet, could be dangerous and cause her to fall again. Most likely she is unable to prepare her own food, shower alone or get dressed without assistance. Based on these conditions, a physician could write an order for her to stay in a nursing home as a permanent resident.
Before you advocate for your grandmother, you will want to make sure that this particular nursing home is the best one for her long-term care needs. You should know that according to a California state auditor report, citations for substandard care at SNFs increased by almost one-third between 2006 and 2015.
As a spokesperson for the California Association for Nursing Home Reform stated, “Nursing-home quality has never been worse despite the fact that some chains out there are reaping historically high profits.”
The main issues are understaffed facilities and patients being pressured to leave before they are ready because they have reached their Medicare coverage limits.
The good news is that there are nursing homes out there that provide quality care; you’ll just want to educate yourself and do some research.
One resource is the Centers for Medicare and Medicaid Services’ guide on how to choose a nursing home (tinyurl.com/cmms-guide). Also check with California Advocates for Nursing Home Reform to see if there are deficiencies or citations of the nursing home you are considering.
CANHR also has information about Medi-Cal and nursing home regulations. Most nursing homes participate in the Medi-Cal certification program. To verify the status of a facility, visit tinyurl.com/status-medical.
Of course, you also will want to carefully review your grandmother’s needs with facility staff to make sure they can be met. You may also want to see if you can get references for the facility.
Once you have selected the best option for your grandmother, you can start advocating for her rights. Because your grandmother is low income, payment for long-term residency at a SNF may be obtained through Medi-Cal. Currently in California, approximately 65 percent of long-term residents are funded by Medi-Cal. A social worker at the nursing home should be able to help you with the application process with the Department of Health Care Services (tinyurl.com/dhcs-info).
Please be aware that there is no such thing as a limited number of Medi-Cal beds or a set number of Medicare beds. Any bed can be a Medicare/Medi-Cal bed.
Because Medicare pays a higher rate to SNFs than other payment sources, if someone isn’t currently being covered by Medicare, nursing homes will often pressure people to move out so they can put another Medicare client in the bed for a rehab stay.
Once you have submitted the Medi-Cal application and obtained a submission receipt, your grandmother’s status will change to Medi-Cal pending. You should give a copy of the receipt to the facility, showing that payment is shifting from Medicare to Medi-Cal.
Because there are strong federal and California laws that protect residents from being evicted, the nursing home cannot evict or transfer Francine if an application for Medi-Cal was made in a timely manner and her eligibility determination has not been made.
If at any time you feel that she is not being treated fairly, you can request a meeting with your local long-term care ombudsman (ltcombudsman.org), who helps residents resolve conflicts with nursing homes. The ombudsman can often assist in stopping an improper eviction or help with an appeal hearing.
Another good resource is the National Consumer Voice for Quality Long-Term Care, which offers publications, updates and news on policy and advocacy for nursing home consumers.
This is a lot of information to absorb. But the more you know and the sooner you start the application process, the better.
You also may want to consult with an attorney who specializes in elder care, or meet with one of the geriatric social workers at Jewish Family & Community Services East Bay.