Managing a Hospital Stay - "MOON" (part 1)

by: Lisa Bayer, J.D., CCM, Advanced Professional member of the Aging Life Care Association

Me: “Is she on observation status or a formally admitted inpatient?”

Client’s son: “My mom is in a private room. She was admitted yesterday evening after spending all day in the ER.”

Me: “Yes, I understand that she is in a hospital room on a floor with other patients—not the emergency room. And I understand that she gets her meals and medications delivered to her room, that she has a TV and phone and even had a consult with physical therapy earlier today. I know that she has been assigned a “hospital doctor” and has consulted with specialists. It certainly may seem that your mom is a patient in the hospital. But is she?”

Client’s son: “I just called case management. You’re right! She is still on something called “observation status.” They are keeping her again tonight but the social worker said she has not been admitted.”

Me: “OK. Let’s talk later after I visit your mom and speak with her doctor.”

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R.S. fell in front of her home. She can’t remember if she tripped over something or if she just collapsed. In fact, she does not remember falling at all. Now in the hospital, she was told that a neighbor found her, called 911, and an ambulance brought her to the emergency room.

As a geriatric care manager one of my roles is to advocate for my clients in the hospital. After speaking with her hospitalist, we learned that R.S. fractured her hip and several ribs and that she is suffering from a severe urinary tract infection. They are not sure if she needs surgery for her hip or if they are just going to set it. She also needs IV antibiotics for the infection.

The first question I asked her doctor was whether she was being treated as an outpatient or an inpatient. Her doctor hesitated a moment and then she admitted that yes, in fact, R.S. was still on “observation status.”

So why does this matter and why is it important to ask this question as soon as possible? Shouldn’t the hospital have an obligation to tell me?

To answer the second question first, the hospital does in fact have a responsibility to inform the patient if they are on “observation.” This is called the Medicare Outpatient Observation Notice or “MOON” and must be presented to the patient or his/her representative no later than 36 hours of starting to receive observation services at the hospital. The presenter is supposed to be able to orally explain the form and answer questions

It is important to understand, however, that even if the Medicare beneficiary refuses to sign the notice the hospital staff person just needs to document that the form was provided. I say “hospital staff” because there is no requirement that the form be presented by a doctor or social worker which would make the most sense. Technically, someone from dietary or even a security guard could present the form.

What happens if a person disagrees with their status or if the form is never presented as required? Nothing as far as the patient is concerned (although there could be financial consequences to the hospital if they are audited by Medicare). To be clear, there are no appeal rights for the patient if they do not receive the MOON nor if they disagree with their patient status.

So what does this all mean to Medicare beneficiaries and how can they protect themselves? Stay tuned for my next article where I discuss the financial and care-related implications for R.S. had she remained on observation status during her hospital stay.

Do I Really Need a Health Care Power of Attorney?

By Lisa Bayer, J.D., CCM

Recently, I was talking to a friend of mine who told me that her mom’s attorney is pushing her mom to appoint a health care power of attorney as she was just diagnosed with mild or “early stage” Alzheimer’s Disease. My friend wanted to know if the attorney was trying to drum up unnecessary business for himself because her dad is alive and well and perfectly capable of taking care of her mom.

I explained to my friend that the attorney was right to encourage her mom to prepare a legal document appointing someone to act on her behalf if and when she is unable to speak for herself. This representative is often called a “health care proxy” or a “health care power of attorney.”

Using her mom’s health care directive (also known as a “living will”) as a road map, this person, in this case her dad, will know what her mom would want if she could speak for herself and will have the authority to make decisions consistent with her wishes. I explained that it is also an opportunity for her mom to appoint surrogate decision makers in case her dad is unable or unwilling to act. Since my friend is an only child and lives close by it might make sense for her mom to name her as well.

Being related does not give someone the right to make health care decisions for another adult—only the health care power of attorney document accomplishes this. In my elder care consulting practice, I have seen difficult cases that have literally torn families apart where there is no health care proxy because the alternative is to go to court to petition for guardianship. The guardianship process is time consuming, financially costly and emotionally taxing. And if the guardianship is contested, this quantifiably increases the time and expense of the litigation.

Given my friend’s mom’s diagnosis, I also explained that there could come a time—and none of us has a crystal ball—where her mom would be unable to appreciate and execute the documents. Her attorney is under a legal and ethical obligation to make sure that her mom has the capacity to sign them.

I told my friend that my suggestion would be to follow her attorney’s advice and have the documents prepared as soon as possible.

When the Care Manager Needs a Care Manager

By Lisa Bayer, J.D., CCM

I’ve had two kids and various same-day surgeries, but last month was the first time I was a fully dependent, admitted hospital patient. I’m in my 50’s so I guess that makes me pretty lucky. While it was elective foot surgery, I had been in excruciating pain for over a year. I felt as if I had no choice but to go through with it. Trust me, I looked for every excuse and reason to cancel the surgery but I just kept coming back to the fact that the pain was not going away—only getting worse.

I had no less than five opinions. Over the course of the past year I saw three podiatrists and two orthopedic surgeons. And five opinions really are five opinions. How can that be if they were all looking at the same x-rays? One doctor made me orthotics. They were no help. Another offered surgery on my “good” bad foot. When I told him I did not want to be off my feet for 6 weeks he said he could reduce that to 4 weeks. When I said that was too long, he reduced it to two weeks. Are we on Let’s Make a Deal? Needless to say I lost confidence in this doctor.

Doctor # 3 taped my foot and arranged for a handicapped placard so I could make it to the Bruce Springsteen concert. He also admitted that the surgery that I needed was way too complicated and outside of his area of specialization. I appreciated and respected his honesty. Three doctors and still no consensus or plan of action.

In between doctor appointments, I had been to physical therapy, massage therapy and a chiropractor (maybe it was my back causing me to walk improperly). Nothing was working and I was still in pain 24 hours a day. I have a high tolerance for pain but it was getting to be too much. My daily activities were affected. I could not walk even short distances. I was losing sleep because I was awoken several times during the night with shooting pain just from changing positions.

In addition to physical pain, it was starting to affect me emotionally. I was using a cane when I wasn’t around people I knew. I was not sleeping well. I had to say “no” to plans with friends and family. Things like my daughter’s college graduation, which should have been all “happy thoughts,” caused me anxiety because I did not know how I was going to negotiate the walking, waiting on lines and being on my feet for long periods of time. I actually worried about this for months if you imagine.

If you saw me, I looked totally fine. As I already mentioned, I have a high tolerance for pain. I rarely complained. If I looked and dressed “normal” and made the right excuses for not doing things like walking around NYC, then there was nothing wrong because no one could see what I was feeling.

After all, it was “only a foot.” But I needed to figure out a plan. So I did my research (this is my professional “wheel house” after all) and found two highly recommended orthopedic surgeons who specialize in foot and ankles and were affiliated with different New York teaching hospitals. I needed to “go big.” Doctor #4 examined my foot and knew immediately what the problem was. He explained that my ligament had torn. The combination of the torn ligament and the resulting deformity necessitated five different procedures. My foot needed to be reconstructed. It was a huge surgery with a long recovery and he did not want me to make any decisions lightly. He told me to come back in two months so that we could talk again.

When I explained to my husband what was going on, he encouraged me to make an appointment for a second opinion so I went to see Doctor #5. I had to point out twice where the pain was mostly coming from. He talked about bunion surgery. That was the least of my problems. Finally, after me leading him down the path (I did not share that I had already seen someone else) he thought maybe I should get an MRI in case I had a ligament problem. Needless to say, I did not have confidence in Doctor #5 either.

So, back I went to Dr. #4. My husband could not physically attend the appointment but we brought him in remotely. We talked again about surgery. It was an involved procedure with a long recovery so my doctor really REALLY wanted me to think it through. When I went back 8 weeks later I was no better. I brought my husband this time. I wanted to see what he thought of my doctor. He asked thoughtful questions that I had not thought about (I was singularly focused on the recovery time) such as the risk of RSD. I scheduled my surgery before I left.

Even though I am a professional care manager here I was the patient. I needed someone else to think of the questions and to share their opinion. My husband insisted on the second surgical opinion and he was right. If nothing else, it solidified my confidence in my doctor.

As a care manager, I always encourage my clients to ask questions and, if appropriate, to get multiple opinions. I also insist that they have an advocate with them at their doctor appointments. We all need someone who will ask the right questions and take notes. This is even more important when someone has memory issues such as Alzheimer’s disease, is hard of hearing or seeing, or is facing a serious illness. Sometimes it is not the surgery or treatment itself but the side effects and after care. For example, any hospital stay or use of anesthesia can cause their own long-term effects for persons with dementia.

LMR Elder Care can help and be “your person” when you are scared and vulnerable. We know the important questions to ask so that you can make informed decisions regarding small or large medical matters. We also make sure that the information is shared among medical providers and family caregivers. This is especially important when you have multiple providers who do not share the same network. In my case, I knew the questions to ask and how to get the information I needed. But I was the patient this time and I still needed my husband to be MY advocate.