Tag Archives: geriatric medicine

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What to check before bringing your elder home from the hospital

I get a call from the hospital (this is over a year ago). They say, “Your friend is ready for discharge. What time can you pick her up?”

I reply, “Can she walk?”

“What?”

“She has three steps up into her house. Can she walk, because otherwise I can’t get her into her home.”

“Oh, uh, we will check.”

They call me back. “She can’t walk. She’ll have to stay another day.”

I knew that she couldn’t walk before they called. She could barely walk before the surgery and after anesthesia, surgery and a night in the hospital, her walking was worse. She had been falling 1-5 times at home and the surgeon knew that. He did not take it into account. The staff would have delivered her to my car in a wheelchair and then it would have been my problem.

She was confused by that afternoon, which is not uncommon in older people after anesthesia. She stayed in the hospital for six days and then went to rehab, because she still couldn’t walk safely.

Recently I have a patient, an elder, that I send to the emergency room for possible admission. He is admitted and discharged after two and a half days. Unfortunately he can barely walk and his wife is sick as well. The medicare rules say that he needs 72 hours in the hospital before he qualifies for rehab. We scramble in clinic to get them Home Health services, with a nurse check and physical therapy and occupational therapy, and I ask for Meals on Wheels. It turns out that Meals on Wheels will be able to deliver in two months.

The wife refuses to go to the emergency room. I tell her that if she does get sicker, that they both need to check in. The husband can barely walk and is not safe home alone. If one gets hospitalized, they both need it.

If you have a frail elder, be careful when you are called about discharge. Go look at them yourself, make sure that you see that they can get out of bed, get to the bathroom, walk up and down the hall. Can they eat? Do you have steps into your house or theirs and can they go up the steps? I got away with saying please check that my friend could walk because I am a physician, because I knew she couldn’t and because there was no one else to pick her up. Do NOT ask your elder. They may want nothing more than to go home and they may well exaggerate what they can do or be firmly in denial. You want them to be safe at home, to not fall, to not break a hip and to not be bedridden.

For an already frail elder, even two and a half days in bed contributes to weakness. And being sick makes them weaker. If they are barely walking when they are admitted, it may be worse even after just 2-3 days. I used to write for physical therapy evaluation and exercise when elder patients were admitted, to help them for discharge. Once I got a polite query from physical therapy saying, “This patient is on a ventilator. Do you still want a consult?” I reply, “Yes, please do passive range of motion, thank you!”

Your elder does not have to be doing rumbustious dancing before they go home, but they need to be able to manage stairs, manage the bathroom, manage walking so that they can get stronger. Otherwise a stay in a nursing home or rehabilitation facility may be much safer for everyone.

For the Ragtag Daily Prompt: rumbustious.


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Fraud in medicine: Diabetic supplies

There is a subtle ongoing fraud in diabetic supplies for diabetic patients and especially medicare patients.

The fraud is in the paperwork. An order form will arrive for me to sign for Mr. Smith. I read the fine print and it says that all of the supplies on the form will be renewed for Mr. Smith, unless something is crossed out. It lists six supplies: lancets to draw blood, strips for the glucose machine, a new glucometer, a new lancet machine and control solution to check that the machine is working correctly.

This is all good and necessary, right? Maybe.

I call Mr. Smith and say, “What do you need?”

“I just need lancets,” says Mr. Smith. “That’s what I asked the company to refill.” He is wondering why I called, because he only asked for lancets.

I cross everything out but the lancets: because that is where the fraud lies. Mr. Smith only renewed his prescription for the lancets, but the medical supply company knows exactly what interval medicare and the other insurances will pay for all of the supplies. They want me to sign a blanket order and then they will send Mr. Smith a new glucometer every time medicare allows, whether he wants and needs it or not. So if you have visited a parent or family member and wondered why they have a closet or a drawer full of some medical equipment, that is why. The doctor did not read the fine print and signed a blanket order and the patient is getting more equipment than they need or want. This is waste and it costs us all money.

Another fraud in diabetic supplies is in getting the first glucometer. I was taught to send the patient to the [diabetic educator] where they would get a “free” glucometer. However, now I tell them to check their local pharmacy instead. The “free” glucometers have the most expensive strips and lancets, and diabetics are supposed to check blood sugar at least once a day. If the strip costs one dollar, that adds up. The pharmacy often has a house brand where the strips and lancets are less expensive. I give the patient the choice. Most of them choose the house brand.

One diabetic equipment company got a hold of one of my patients and wouldn’t let go. They sent paperwork to me saying that they needed every note back to the date that I had prescribed his equipment and copies of his blood sugar records. I wrote them a letter, saying, “I am sending the notes, but I don’t photo copy the patient’s blood sugar records. You are being unreasonable. My notes contain the records I made about his blood sugars.” The company is in Florida and the patient is in Washington. The company kept demanding the notes, all the way back to the first visit, every two months. After we sent them twice, we sent a letter saying, “We already sent those twice. We’re not doing it again.” They continued to fax renewals. I talked to the patient. He wanted them gone too, because they kept calling him and wanting to send him more supplies. I called them. They did not desist. I sent them a letter and tried calling medicare fraud. The medicare fraud department said, “Call the company.” Now we just shred anything they send us, including the threatening notes saying that medicare will be after me.

The diabetic supplies aren’t terribly expensive, but when there are millions of diabetic people, this adds up. Also, most physicians are so busy that they sign papers without reading all that fine print and don’t have time to check what the patient really needs. And the companies are targeting the frail, sick and elderly, though many diabetics are otherwise healthy. I think it is a shameful scam to have a person call a company and say “I need more lancets,” and then to try to send them more of everything. Isn’t that illegal? It should be, to fill prescriptions that have not been renewed. I am tired of seeing more and more clearly how our United States medical system is a system to make money any way possible, and morals don’t matter, and it has nothing to do with people’s health.

http://www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html
29.1 million diabetics in the US
21.0 million diabetics diagnosed in the US

published on everything2 on November 26, 2014 and on Sermo today