Health Care Failure and Redemption Part Two

Following the blog posted yesterday I presume there is some curiosity about how this turned out.

Here is the rest of the story…

My loved one arrived home later in the afternoon on Thursday 5/15/25. When I realized that Home Health had not been ordered I immediately discussed with my loved ones, and we once again determined that Home Health would be crucial to assure safety at home.

My first call was to the Home Health agency we had picked, to make sure they had not received an order for Home Health that we were not aware of at the time of discharge.  They had not received any information, and this was around 4:30 pm. I knew limited time was remained to get anything from the hospital, so I placed a call to the case management office and was told by the case manager that my loved one had declined a referral to Home Health. If you remember from Part One, they were not asked about Home Health on DC, and I also learned that on admission they had requested a Home Health referral when they were going home as a part of a routine intake questionnaire. The case manager also informed me that the patient had been cleared by Physical Therapy during their one visit Saturday morning the 10th of May. The case manager also stated that my loved one did not score on a “standardized DC score” as “needing” Home Health. I of course asked to speak to a supervisor, and she had me hold while she spoke to her supervisor and came back on phone to say there was nothing they could do because the patient had already been discharged.  She recommended we call my loved one’s primary physician.

While my loved one is very mobile for her age, I did not witness any evidenced based tests performed by clinicians but did witness dynamic mobility challenges and interview questions. Keep in mind that after this evaluation only my 85-year-old loved one remained in the hospital for another 5 days and was never evaluated again. She remained primarily in bed due to the hospital’s fall precautions which included bed alarm and camera surveillance. Being a PTA I attempted many times to walk with my loved one only to be admonished to wait on a nurse or tech. I made sure she walked to tolerance at least 2 x daily.

I contacted the Home Health agency again Friday 5/16 at around 10:30am to let them know where we were. I called and left a message for my loved one’s primary care physician who was very aware of what was happening as she had been in contact with my loved one throughout her stay at the hospital. The Home Health Agency intake lead assured me that they had received many referrals from the primary care MD and would follow up as well to get a referral as they had a nurse ready to get my loved one admitted ASAP on Friday or Saturday morning.

 

Following an additional follow up call with the HHA to see if they had received any information, my loved one received word from the primary MD that they would not be writing the order for HH until after the visit scheduled with them today 5/19/25. They said they did not want to risk my loved one having to pay out ot packet for a nurse to visit if the order occurred before then (insert F2F education moment here for MD). My loved one had seen their primary care physician multiple times leading up to the hospitalization within the 90-days required.

Back to the hospital I went. I phoned the charge nurse on the floor several times attempting to see if the hospitalist could write the order as they were very aware of our request and my loved one’s need for HH.

My loved one’s spouse, in the meantime, had filled all the new medications and was feeling overwhelmed. Upon query I realized that they had never monitored blood glucose and had only been using metformin and diet for DMII up until this time, so they had no idea what her glucose levels were, and she was still taking high-dose steroids. This was another shocker that the hospital discharged my loved one without a glucose monitor, nor education on how to do injections, etc. Turns out there was another twist, my loved one was discharged on her pre-hospital Metformin 1500 mg only, despite having blood sugar levels between 200-400 while in hospital.

Before I could get a positive answer, I asked to be transferred to the hospital risk management department and requested to speak with a risk manager. While I tried to explain the obvious oversight and risk my loved one had been placed into, the department secretary was not hearing me, because at one point she said to me “why don’t you go ahead and sue us.”  To say I was flabbergasted is an understatement and I filed this away in my mind to make sure I made the risk manager aware when I received a call back.

She also had me call the “Patient Experience” department and I am still waiting on a call back as I type this today.

Thankfully, following my second call to the floor charge nurse I was transferred to a different case manager who transferred me to the supervisor for case management who is one of the heroes of our story. She tracked down the hospitalist and got them to write an order for Home Health that was received by the wonderful agency at 4:30 pm on Friday and the nurse admitted my loved one to HH on Saturday morning by 11am.

This entire ordeal took almost 6 hours of my time on Friday 5/16/25. Because of the misadventure, I now know who to call and how to work this “broken” system we call Home Health. This made be a believer that anyone over the age of 65 should be referred to Home Health.  Home Health should decide who is and is not eligible.

In conclusion, I did receive a call back from the risk manager and I shared the “why don’t you go ahead and sue us” statement with her, she was shocked and said she would handle it.

I also received a follow-up call from the floor Nurse Manager to make sure it had all gotten taken care of and she shared that she was opening a grievance because in her words “our system is evidently broken.” She also shared, without details, that this was not the first issue with case management and the post DC care her patients receive is “dulling the shine” on the excellent care they provided my loved one and she could not allow this to continue to happen. She was appalled that the only interaction or documentation she could see in my loved one’s chart regarding interaction with a case manager was on day one (intake) and the last day (discharge). She said the hospital standard for the “vulnerable” populations was everyday contact.

The case management supervisor also called me back to get a full accounting of how the original call to her department failed to get the outcome we needed. She seemed to want to fix the issue in her department.

I hope this does not happen to anyone else.

 

A few follow-up questions:

How often is this happening in your local hospitals?

What system (s) do you have in place to educate providers and case managers about home health and our ability to determine when patients are appropriate for our setting?

What system do you have to educate your current patients about how they can advocate for themselves to get the care they need?