What to expect when Mom lands in the ER with a broken hip

[The following article originally ran in 2017. I have updated some details below.]

Six weeks ago, our dear 77-year-old neighbor Dee fell while going out to water her yard. It was a fluke accident, simply a misstep, while she was trying to loosen a hose. Her hip hurt, but Dee was more worried about her elbow – until she tried to stand up. The pain was excruciating. An unfortunate factor was that both her children were out of the country at the time. We, her neighbors, were also out of town. She didn’t have a medical alert device on – she had never needed one – and her phone was inside. The fortunate factor was she lived on a busy street and a kind couple heard her cry for help. They called 911 and within minutes, the ambulance was there to transport her to Duke Raleigh.

Dee is far from alone. According to the U.S. Centers for Disease Control and Prevention, one in four Americans over 65 falls every year. Over 300,000 of these falls result in a hip fracture. The one-year mortality rate for people over 60 who experience a hip fracture is 21 percent. Typically, the person knows right away that something is very wrong. It is best that they not try to move until an ambulance arrives to safely transport them by stretcher.

In the emergency room, Dee had an X-ray, which confirmed she had broken her hip. She was admitted to the orthopedic floor and scheduled for surgery the next day. They said she could expect to be in the hospital for a minimum of three days, in the best case scenario, up to a week, in the worst case. (A patient’s length of stay is determined using very specific markers that are set by Medicare and insurance companies and assessed by physicians). After that, a patient is typically discharged to a Skilled Nursing/Rehabilitation Facility ("SNF/Rehab," for short). The average amount of days a person spends in rehab after a hip fracture is 25-31 days.

Dee’s daughter Carolyn arrived the night Dee was admitted to the hospital. The case manager, who is usually a nurse or social worker employed by the hospital, gave her a long list of the Skilled Nursing Facilities (also called “SNF”) in the region. There are 29 in this region, with a wide range of quality. Some rarely have an available bed. Some always do. The case manager is not legally allowed to offer any recommendations.

Carolyn identified the six that were most convenient for their family and set out to tour four right after Dee’s surgery was over the next day.

For those who don’t know, this is the process for finding the best rehab/SNF to match your family’s needs. On admission to the hospital, the case manager (who is typically managing 15-20 patients concurrently) provides the family with a comprehensive list of options. The case manager is simultaneously also sending out an FL-2 on your loved one to all 29 facilities. The one-page FL-2 is a standard form that specifies a patient’s recommended level of care at discharge from the hospital, their medications, what kind of insurance they have and a number of other factors (like whether they can perform personal care, walk, communicate, eat, use the bathroom, etc.) Beds at the best places are snatched up quickly. Beds at the worst remain open and empty. The family comes up with their ranked list of three options that the case manager has confirmed will accept the patient, and then the case manager calls the places back to see if the bed is still available. The availability of beds changes day to day, or even hour to hour, as people are admitted and discharged.

The hospital will seek to place the patient in one of their top three choices. If that is not possible, the hospital will ask the family to pick a fourth.

What are the most important considerations? Location and quality. Dee’s daughter, Carolyn, mapped out which Skilled Nursing Facilities were close to her brother’s home in Raleigh. She then used Medicare.gov to see the ratings of the eight most convenient ones. Medicare.Gov provides a 1- to 5-star rating system measuring quality of care, safety and staffing. It also allows families to compare facilities side-by-side. Carolyn visited four.

Patti Ryan, a case manager at WakeMed for over 20 years, said, “It is very important to look at quality of care over appearance.”

Carolyn gave Dee’s case manager their three top choices. Fortunately, one of their choices had an available bed. It’s important to note that if Carolyn and Dee suddenly decided that they didn’t want to go to this particular rehab after all, then they very well could have to foot the daily hospital bill until they could find another match.

The hospital case manager then arranges transportation from the hospital to the rehab by ambulance.

Dee arrived in a semi-private room at Hillcrest on a Friday afternoon, and she started physical therapy (PT) the next day. She received physical therapy and occupational therapy (OT) on alternate days.

Naturally, Dee’s first two questions were, “When can I go home?” and “What is this going to cost me?” Like the hospital, the SNF is required to ensure the patient has achieved specific markers before discharge to ensure safety and also avoid a readmission.

Hillcrest estimated rehab could take two weeks. Dee was lucky. She achieved her PT and OT goals more quickly and, because she lived with her children who could provide round-the-clock home help, she was discharged after one week, with the caveat that she have a hospital bed, wheelchair, walker and medical orders for home OT and PT in place before leaving.

In Dee’s case, Medicare Part A covered the bulk of the cost of her hospital stay at Duke Raleigh and her rehab stay at Hillcrest. Medicare Part B covered most of the costs of physical therapy and occupational therapy at home, as well as the rental fees for the hospital bed, walker and wheelchair. Her Medicare Supplement Plan F covered the rest. It is important to note that Medicare Part A covers skilled nursing care in a semi-private room for the first 20 days 100 percent, provided the patient was first admitted for three nights to a hospital and is still progressing towards well-defined goals. Medicare Part A coverage decreases to 80 percent in a skilled nursing facility for days 21-100. While costs fluctuate, the cost for a shared room in a skilled nursing facility can run from $190/night up to $300/night in Wake County.

What advice would Dee give any family going through this in the future? “You need a family member in the room with you as much as possible and also keep a sense of humor. Almost everything else is out of your control.”