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Carl, a 65-year-old man, came into my office as a new patient about 16 years ago for a headache. He told me he had been in the emergency department the previous day and that they diagnosed a sinus infection and gave him a prescription for antibiotics. I took a history, performed a physical exam, and diagnosed him with shingles.

He became an established patient, as did his wife, Sally. Over the years they were seen for health maintenance issues and emergencies, like Carl’s heart attack that led to bypass surgery and Sally’s onset of atrial fibrillation. Sally and Carl were high-school sweethearts and their only child died in an accident.

About 10 years ago, my wife and I went to dinner at a local diner and saw Sally and Carl. We stopped by to say hi and they asked us to sit down. That started our friendship, with weekly dinners at that same diner (and occasional trips to the ice cream parlor, despite Carl’s diabetes).

Fast forward to February 2016, when Sally died suddenly, leaving Carl alone. This was not supposed to happen; she was the healthy one, she paid all the bills, she took care of Carl. As any good friends would do, my wife and I stepped up and helped Carl. I was able to gain access to all the accounts Sally had set up online and ensure that Carl’s bills got paid. By this time, I had left clinical practice, so Carl was no longer a patient and solely a close friend.

But it was not until Carl needed hospital care that I was able to see things from the patient’s side and realized the profound effect that case management and Medicare regulations can have on care. Carl’s arthritis in his knee got bad enough that he needed surgery (yes, he failed outpatient therapy, had an adequate trial of analgesics, required a cane to ambulate, and it was affecting his activities of daily living – and yes, all these facts were documented in the hospital medical record). In the meetings with the surgeon, Carl discussed the fact that he lived alone in a split-level townhouse with multiple steps and that he had no family to stay with him. The surgeon assured him he could go to a skilled nursing facility (SNF) after surgery, never mentioning the three-day hospital stay requirement.

Lesson Number One

Lesson number one for me: doctors still make promises to patients without understanding the potential consequences.

Post-operatively, Carl received a small dose of oral narcotics and the first post-operative day, he became delirious. (Secretly, I was delighted, since I knew that would get him the three days he would need to access his SNF benefit). The care at the hospital was excellent. Call lights were answered quickly. A few caregivers entered the room and had to be asked to wash their hands. The doctors often did not wash their hands, but then most never even touched Carl, so the risk of transmission was low. Each person introduced himself or herself and explained their role; that was crucial to Carl, as he was already overwhelmed with new people even before his delirium and the effects on his memory. The case manager explained that the transportation to the SNF was not a covered benefit, so we could either drive him or pay for a medi-van. We appreciated this; what we did not want was a lot of unexpected bills once Carl got home.

Lesson Number Two

His stay at the SNF was helpful; he worked hard in therapy knowing that he would soon have to navigate his steps on his own at home. It was then that the first rumor of SNF care proved to be true. After about two weeks, we took Carl out for a home visit and he handled the stairs well. We thought he was ready to go home with home care. But the social worker at the SNF who handles discharge planning would not return our calls. I had to call the home care agency myself to set up a referral. It was not until day 19 of the stay that the social worker contacted us and we planned discharge for the next day.

This was lesson number two for me. It sure looked like the SNF knew exactly when his 20 days of 100-percent Medicare coverage was ending and made sure that Carl stayed until that lapsed. This was not a car salesman adding rust proofing; it was a healthcare facility seemingly holding a patient hostage for their financial gain.

Once home, his progress was slow and steady. And then he needed back surgery (yes, he tried physical therapy, multiple epidural injections, was back to using his cane, and had trouble with his stairs). He could not take opioids after his delirium episode, so back to surgery he went. Post-operatively, with the best of intentions, the surgeon ordered Percocet, not wanting Carl to have severe pain. And as we predicted, back Carl went into his delirious state. He also developed tachycardia and the hospitalist started a beta blocker. The next day he went into atrial fibrillation and a different hospitalist started diltiazem and warfarin. He went to rehab two days later, once his delirium cleared, and some can probably guess what happened: he had a syncopal episode from bradycardia.

He was sent to another hospital near the rehab facility, as observation for this episode. I was in the room when the registration clerk arrived and he was handed a piece of paper to sign. I glanced over and noted it was the Important Message from Medicare (IMM). When I asked the clerk why he was getting the IMM if he was being placed in observation, it was met with a blank stare. I started to explain Medicare regulation to her, but my wife stepped in, reminded me that I was there as Carl’s friend and not as a Medicare regulation expert, and told me to shut up.

Lesson Number Three

Here was lesson number three: many hospitals still do not have the patient notification hardwired, much to the detriment of patients.

When the hospitalist arrived to take the history, we were able to piece together the events: at the prior facility, the second hospitalist did not realize the beta blocker was a new medication and therefore thought Carl needed more rate-controlling medication and added diltiazem.

Lesson Number Four

The above served as lesson number four for me: the lack of a single physician following the patient throughout the course of a hospital stay can have significant adverse consequences.

Since Carl was back in normal rhythm, the medications were stopped and he did fine. The next day he was not transferred back to rehab because the hospital contacted the rehab facility too late to set up the transfer that day. We were told he would go the next day, a Saturday. Since Carl would pass the second midnight, out of curiosity I asked if he was being admitted as inpatient or left in observation, and once again I got blank stares. Of course I knew that there was no indication for admission, but was surprised that no one seemed to be aware of the two-midnight rule or saw any need to transfer him prior to the second midnight, even though he was clinically stable.

Lesson Number Five

Lesson number five was that bureaucracy often gets in the way of good patient care; Carl was now going back on Saturday, would arrive after the therapists had left for the day, and would not get physical therapy until Monday.

Eventually, Carl made it back home and is doing well. He knows he is never allowed to take an opioid medication, no matter how mild the pill or how severe the pain. And I learned that as easy as it is to teach regulations, actually implementing them and disseminating them to every person that needs that knowledge is difficult. Carl’s episode with delirium from opioids and syncope from two rate-limiting medications reinforced for me the concept of “less is more.” I also saw the dark side of healthcare with Carl’s needlessly extended stay at the SNF.

Carl, as a widower with no family in the area, has also made me more circumspect when asked about what to do with a patient in the hospital who has no need for hospital care, but would not be safe living alone. I still don’t have a good answer, but I see the real pain that it can cause.

Every day, each one of us goes out and tries to make a difference. Many of us are no longer at the bedside, taking histories, doing exams, ordering treatments, and providing care, but that does not make us any less important to the patient.

We all matter.

Let’s all make sure that we are all doing the best we can.



Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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