Dementia and Physical Therapy: Medicare Requirements

Dad has Alzheimer’s disease.  Generally he seems to function about the same as he has for several years already.  His memory is slowly fading but he hasn’t quickly deteriorated.  He still remembers that he likes to go to thrift stores, that he likes pasta for lunch, that he worked for the same company for essentially his whole career and that he was a US Marine in WWII.  He understands instructions and generally follows them.  However, he does have a bit of a hearing problem and one has to look directly at him when giving instructions.

After his 10-day stay in the hospital, dad was discharged to a Nursing Home because he had an open wound where a tube was inserted (similar to a Foley catheter but through an incision into his bladder).  Ruby Court, his assisted living facility, wouldn’t take him back until the catheter was removed and the incision covered and healing.

While he was in the nursing home, I expected he would get physical/ occupational therapy twice a day to teach him how to handle his urine bag (hooking it to the side of his walker when he walked to lunch, etc).  Therapy was also supposed to assure that he was back to walking normally after almost 2 full weeks in bed.  I hoped they would also teach him to wash his hands regularly as he wasn’t doing that.

Three days after dad entered the nursing home, I was given written notice that Medicare would not be paying for his nursing home care.  I requested clarification as he had come directly from the hospital and I expected he would go back to his assisted living facility after a short-term rehabilitation period.  It seemed the nursing home had different ideas.

Since dad was able to privately pay for his stay, they planned for him to get long-term custodial care at the nursing home.  They did not expect him to be discharged – EVER!  I asked why Medicare wouldn’t pay for the 1st hundred days in full or in part as the Medicare booklet details.  They said Medicare will only pay if (1) the patient requires at least 1 hour per day of skilled nursing care (like changing wound dressings, giving IV fluids or shots, etc.) OR (2) the patient is receiving physical or occupational therapy.

I said I sure expected my father was getting physical therapy.  No, they said, he has been discharged from physical therapy.  Naturally, I asked why as it seemed to me that he needed it and the therapists were right there, and we were paying almost $400 per day for this care.  Well, they said, (1) dad refused physical therapy and (2) the physical therapists determined that “He would NOT BENEFIT from physical therapy”.  And Medicare will only pay if the patient is improving from the therapy.  So, without even trying, they made the decision at he wouldn’t get physical therapy.

I was extremely upset by this turn of events.  I felt the nursing home was being arbitrary about this decision as my dad is capable of learning to care for himself.  I said I sure wasn’t planning for him to stay forever in a nursing home getting purely custodial care.  If he just needed custodial care and not nursing care, why was he in a nursing home in the first place?

The answer of course was that he had the catheter tube that was in a fairly new incision – an open wound essentially.  With his dementia Ruby Court, his assisted living facility, feared he would just pull out the catheter, forgetting it was there, leaving an open would and then they would have a medical emergency to deal with.  Since they only had a nurse present weekdays, that would not work for them.  So he had no choice but to go to a nursing home.

Fortunately, for us, when dad saw his specialist for his follow-up visit (after discharge from the hospital), the specialist removed the catheter that went directly through the skin to his bladder and replaced it with a Foley Catheter.  The specialist said in a week he would remove the Foley and everything would be back to normal.  Once I notified the Ruby Court nurse about this, she set up an appointment to come out with the manager to visit with dad and determine if he would be re-accepted to his assisted living facility.  One week later, he was back to normal and approved to go back to Ruby Court.

All this took weeks longer than it should have because it started in November before the holidays.  Even before Thanksgiving, staff started taking vacations, and follow-up appointments couldn’t be scheduled.  Dad’s last follow-up appointment had to be postponed an extra 2 weeks because it had to be on a Monday (the day the doctor was in that office) and it couldn’t be Christmas or New Years’ Day.

So, you might ask, what are the rules about what Medicare will pay for?

Medicare will help pay for outpatient physical and occupational therapy, and speech pathology services if:

  • They are medically necessary;
  • Your doctor or therapist sets up the plan of treatment; and
  • Your doctor periodically reviews the plan to see how long you will get therapy.

Generally, Medicare will only cover therapy if your condition can improve or if your condition will deteriorate without therapy.  See “Medicare”:  “Will Medicare Pay For Outpatient Physical, Occupational or Speech Therapy?” 

Note:  The link above is still correct but it has been updated since this post was written.  After a lawsuit  the Medicare rules changed and now a patient will be covered by Medicare if Physical Therapy helps him maintain abilities and he need not show improvement to benefit from this therapy.  It even covers if physical therapy helps slow the loss of functions.  So refer to the Medicare link for the most up to date information on Physical Therapy and Medicare.

You learn something new every day.  (Whether you want to or not!)

About letstalkaboutfamily

I am a retired and was the primary caregiver for both my parents before they passed. I have children and grandchildren. This blog is an attempt to connect with other caregivers and share ideas and experiences. I hope you will let me know what worked for you if you had an experience similar to mine. The main issues I am going to talk about are elder care, death and dying, assisted living, family relationships and hoarders and hoarding. Other topics will come up as I address the issues and my relationship with other family members.
This entry was posted in Alzheimer's Disease, Assisted Living Facility, Dementia, Eldercare, nursing home and tagged , , , , , , , . Bookmark the permalink.

1 Response to Dementia and Physical Therapy: Medicare Requirements

  1. These rules have changed due to a lawsuit against Medicare. Look for updated information for now people with Alzheimer’s and PD should be able to get Medicare to pay for Physical Therapy even when they don’t improve. I will try to write more on this sometime in the near future.

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