By: Joseph L. Romano, Esq.
Discharge dilemmas, a problem that is becoming increasingly prevalent for families, acute care hospitals, and rehabilitation facilities is the difficulty of discharging patients with traumatic brain injury (TBI). Often, a payer of rehabilitation benefits gives the facility notification that the payment will cease on a designated date, but the hospital is unable to arrange the discharge by that date, leaving them with nowhere to discharge the patient with TBI and no means of billing to cover the continued stay.
The discharge dilemma often evolves when skilled nursing facilities determine that the level of care of the patient is going to strain their personnel resources, there aren’t any family members who are capable or willing to care for the patient, and the patient cannot be sent home due to problems with accessibility. The dilemma is further complicated by the “realities of home care”:
- Coverage for skilled and attendant care is inadequate
- Most policies have limited inpatient and outpatient therapy benefits
- Insurance policies do not pay for home modifications
- Transportation to medical appointments is not a covered benefit
- All state and federal benefits are being reduced
- Insurers anticipate that you will not have someone to advocate for your benefits
Discharge planning for TBIs becomes more complicated when a patient has one or more of the following conditions:
- Patient is at risk of falls
- Patient cannot self-direct his or her own care
- Ventilator dependency
- Tracheotomy
- Feeding tube
- Seizure disorder
- Neurogenic bladder requiring intermittent catheterization
- Behavioral problems
- Insufficient family support system
- No one is available to independently advocate for the patient
The promise of adequate home nursing and attendant care often gives families a false sense of security, and they agree to the discharge, believing that they will have the assistance that they will need, only to have their home care benefits reduced or terminated.
Since funding for comprehensive home care services is often inadequate, I report here the development of novel funding options that pay for extracontractual benefits (ECBs) needed by many of my clients.
ECBs are benefits that are generally not covered by insurance policies, but they are often the supports and services that are needed to safely discharge a patient to home.
I have used novel funding approaches to pay for the following extracontractual TBI benefits:
- Extended inpatient rehabilitation
- Additional outpatient therapies
- Increased hours for skilled nursing and attendant care
- Stair glides
- Respite care
- Functional electrical stimulation cycling
- Home modifications
- Ramps
- State-of-the-art prosthetics
- Coma recovery programs
- Accessible housing
PRELITIGATION FUNDING AND LETTER OF PROTECTION
The two novel funding approaches that I have successfully used to pay for extracontractual TBI benefits are as follows:
Prelitigation Funding: This is a type of funding accessed through private companies that agree to advance funds to pay for home care services and ECB. Your attorney will negotiate the amount the company will lend you. A contract is entered into between the injured person and the company that states that the lender is reimbursed only if the litigation is successful. Prelitigation funding can be used for a wider range of ECBs than a letter of protection (LOP).
Letter of Protection: An LOP is an agreement between the injured party and a vendor to provide home care services and wait to get paid at the conclusion of the lawsuit. Before agreeing to this, vendors including nursing agencies, equipment providers, therapists, rehabilitation facilities, and contractors will require a written contract confirming the terms of the agreement. The LOP is signed by the injured party (if competent), parent, or natural guardian for a minor or court-appointed guardian for an incapacitated person. The vendor will be repaid for services rendered only if the litigation is successful.
To determine whether a patient is eligible for an LOP or prelitigation funding, services of the investigators and experts are used to examine the facts and circumstances of a particular case to identify whether there is a party or parties liable for the disabling injury.
MONEY = OUTCOMES
Studies show that individuals with TBIs who have access to funding will maximize their long-term rehabilitation gains. 1,2 Families and rehabilitation staff need to ‘think outside the box’ to identify and secure skilled nursing and attendant care, state-of-the-art equipment, home modifications, transportation, outpatient therapies, and other home care benefits.
CONCLUSION
If families and their healthcare provider do not consider using novel funding strategies, it is unlikely that patients with TBI will receive adequate services at discharge. Discharge planning for patients with TBI should begin at the time of admission to a trauma center or rehabilitation facility. Delaying discharge planning may now allow ample time to implement prelitigation funding or LOPs in order to put TBI services and supports into place. There is no universal solution to the problem of obtaining comprehensive home care, and each individual case must be closely evaluated by social workers, case managers, hospital discharge planners, and an advocate/attorney for the family. The use of novel funding approaches can provide many families with relief from the burden of care, allowing patients to remain comfortably in their home and avoiding nursing home placement.
REFERENCES
- Kozloff R. Networks of social support and the outcome from severe head injury. J Head Trauma Rehabil. 1987;2(3):14-23.
- DeJong G, Batavia Al, Williams JW. Who is responsible for the lifelong well-being of a person with a head injury? J Head Trauma Rehabil. 1990;5(1):9-22
Author Affiliation: Law Offices of Joseph L. Romano, Blue Bell, PA.
Mr. Romano is an attorney who represents children and adults throughout the United States who have suffered catastrophic brain injuries, spinal cord injuries, and other serious injuries and illnesses. He is the author of Legal Rights of the Seriously Ill and Injured: A Family Guide and Unique Funding Options for Trauma Patients.
Updates can be found on the Web site: www.josephromanolaw.com.
The author declares no conflicts of interest.
Corresponding Author: Joseph L. Romano, Esq., Law Offices of Joseph L. Romano,
583 Skippack Pike, Suite 500, Blue Bell, PA 19422 (info@josephromano.law.com).