`Twas a week before Christmas
and all was not merry,
The ICU full and staff more than weary,
We all wondered why
and finally asked...
Why is he here?
He certainly won't last.
His loving wife
had learned all the tricks ....
The suction, the vent,
the tube feedings Q 6.
She'd moved to a home
without steps or stair
So why was he here when he wished to be there?
The nightmare continued,
what could mere nurses do?
67 days and counting
in the same ICU
As we sat around grousing
a plot we did hatch...
And soon set to work
with a swift dispatch.
The discharge planner
was gone for a day...
While she wasn't looking
we'd wisk him away.
To enjoy in his home
this last Christmas Day!
Perhaps the aspects of insurance fraud are more clearly communicated in prose as I revel in the joy of knowing that Mr. Newman* did not have to spend his last Christmas isolated from his family on a ventilator and tube feedings in the Intensive Care Unit..
Mr. Newman had been healthy and active most of his 53 years until about five years ago when he started having dizzy spells and frequent falls even when walking on level ground. The
diagnostic procedures were intense and expensive, but his loving wife of 38 years stood by him even when the diagnosis of ALS (Lou Gehrig's Disease) was finally confirmed.
By December of 1995, they were both fully acquainted with the irreversible nature of this progressive degenerative disease and by then he had been confined to a room in the intensive care unit on a ventilator for nearly two months. Mr. Newman was hemodynamically stable and his heart rhythms were normal, but still we couldn't transfer him to the medical floor (less expensive care) because he was "on a ventilator." Mrs. Newman had watched and learned. She did all of his care whenever she was there and she was there at least ten hours per day even when the snow storms made the roads nearly impassable.
Mrs. Newman begged me that night to find a way for her husband to go home for his last Christmas. She told me how previous nurses had scoffed at the idea of her caring for him at home and how the discharge planner had been quite adamant in her statement to Mrs. Newman that morning. "I've never sent a patient home on a ventilator!" was the statement that finally drove Mr. Newman to tears.
I reviewed the discharge planner's notes in Mr. Newman's chart, but they didn't make sense to me. The discharge planner had refused to let him go home a month previously because their house had a front porch with steps. But Mr. Newman was confined to bed...he wouldn't need to worry about the steps once the ambulance attendants brought him home. Never the less Mrs. Newman had sold her home and moved to one that did not have steps. Then the discharge planner wouldn't let Mr. Newman go to this new home until it was rewired by a licensed electrician to accommodate 30 amp fuses. Again, the logic seemed to be missing. I added up the amperages on all of Mr. Newman's equipment and determined that unless he had all of his equipment plugged into the same socket and he was actively using the ventilator, while being suctioned and going up and down in the bed, 15 amps would more than adequately accommodate his needs. After seeing Mr. Newman in tears, the discharge planner had written just one last comment, "may only be discharged to skilled nursing facility, not to go home." Having read all this, I was surprised her signature was anything other than Ms. Grinch!
But back to this logic thing ....
We can't transfer Mr. Newman to the medical floor because the nurses there aren't trained to manage a ventilator, but we can send him to a skilled nursing facility where the staff has far less training than even our medical floor? And what about the insurance company's case manager? Where was he/she when Mrs. Newman demonstrated not only her willingness, but her ability to manage Mr. Newman's care at home? One might wonder if Ms. Grinch and the case manager had some kind of a kickback scheme going with the skilled nursing facility.
I worked diligently that night. Ms. Grinch would be off in the morning and that would be Mr. Newman's chance to escape! I fixed a cot for Mrs. Newman and made her promise to sleep. I would wake her at 05:00 am and complete my documentation of her demonstrations of care techniques. I prepared detailed lists of supplies that would be needed at home including gloves, extra trach sets, feeding bags and the like. I described in detail all the care techniques Mrs. Newman had been taught and recommended daily home nursing visits for the first week to help work out any problems that might arise. I prepared trouble shooting guides for the ventilator, suction machine and feeding pump. I prepared instructions on vital signs, respiratory and physical assessments. I even prepared an equipment cleaning schedule for home use. Ten pages of progress notes later, I finally had it covered.
Mrs. Newman started her care demonstrations promptly at 05:00 am. By 7:00 am the day shift nurse had already placed a call to Mr. Newman's attending physician requesting an order for discharge home and was busily conspiring with me to complete this plan.
I understand it took until 2:00 pm for the ambulance crew to finally deliver Mr. Newman to his new home, but even then it seemed like a miracle. Their four adult children were ready for their arrival greeting them with a decorated tree because word of their incredible escape had leaked out in advance. I had spent more than two years of my career as a Registered Nurse doing nothing but ventilator home care. Now all I had to do was prepare for the explosion when Ms. Grinch returned to find Mr. Newman had been discharged home without her consent.
To this day, I can't help but wonder how Ms. Grinch was able to justify Mr. Newman's extended stay in ICU when Mrs. Newman was already documented to have the necessary skills to take him home. And then, of course, what might happen to a recently widowed Mrs. Newman if the insurance denied coverage for the care they didn't want or need, but were forced by the discharge planner to accept?
* Names were changed in the interests of privacy.
And finally, if things are still suspicious and yet inconclusive, consider requesting a change of home health agency on the case...it might prove very enlightening.
This article was published in the John Cooke Insurance Fraud Newsletter.