Life Sciences

Family influence heightened during clinical meetings

Medicare & Reimbursement Advisor Weekly, May 27, 2009

Around the continuum

On the weekends, I’ve been doing some social work in nursing homes and acute care settings as a designee, assigned by facilities to assist families as an advocate and resource support. In this work, I have an opportunity to sit in on family meetings with case managers, discharge planners, medical directors, floor nurses, Medicare and commercial insurance staff, and pharmacists. Since April, I’ve attended three family meetings at Kimberly Hall, a Genesis nursing home chain in Windsor, CT, and two meetings at Yale New Haven Hospital. A physician or medical director attended two of the five meetings, probably because two of the cases were clinically more severe (including one of a 65-year-old male in a persistent vegetative state). Generally, physicians and pharmacists do not attend these meetings.

Below are some observations from these meetings:

  • The meetings were held two weeks after admission (fairly typical).
  • The director of nursing was not present, except in one case.
  • Social services opened the meetings and handled all referral/home health questions.
  • The unit nurse manager seemed to run the meetings.
  • Nursing staff: Only one time was a floor nurse present.
  • The family educated the nursing staff about signs and symptoms recently observed.
  • The medical director/physician was typically unaware of the family’s observations (multiple times).
  • The family questioned side effects and the efficacy of drug regimen in four meetings.
  • The nurse manager was always willing to recommend treatment options to the MD.
  • Commercial insurance rep talked about how Anthem BC wanted the patient to be exhibiting goals or it would cut reimbursement and force the family to take the patient home or pay privately. Reimbursement in one case was cut by 22 days before the benefit was reached.
  • The family wanted Medicare to pick up the benefit for a three-week period after the Anthem days were up. The nursing home said it would pay under Medicare Part A per diem, but would not, in this case, be able to try an expensive pharmacy regimen:
  • For example, in the case of the 65-year-old, Yale’s neurologist started the patient on a series of two- to three-day psycho stimulants (Ritalin, Amatadine, Sinimet, then Zoloft). With Zoloft, the order was written for 30 days. The nursing home followed the order, but after 25 days, the patient had not exhibited a benefit and had suffered side effects. The physician agreed to meet with a consulting neuro-psych pharmacist to discuss other options.
  • The family ultimately urged the nurse manager to facilitate a meeting with the medical director and hospital physician. The meeting was held within four days by phone, with the family present.
  • The family asked the MD at one meeting whether an additional “full neuro workup” could be done. It was ordered and conducted within 48 hours. —BC,