Ditto, all of this. My mom had a similar experience after her shoulder replacement surgery a few years ago. The hospital did excellent work with the surgery and immediate post-op care, then completely fumbled the ball. Two days later she was back in the hospital for two weeks.
Would have been cheaper all around to have arranged to keep her for at least a week post-op. But that's typical false economy built into the current system we have.
We warned them that mom strongly overreacts to anesthesia and morphine for pain. And her subconscious survival skills fool a lot of people into thinking she's just fine, when actually she's responding only superficially appropriately to basic questions like "What is your name, where do you live, who's the president?", etc. Later, she won't remember a thing. And it usually takes her weeks or months to mentally recover from the effects.
That's been a common theme with her medical care system. The doctors and nurses do great work. But there is zero follow-through. Three times they've dumped her with no follow-through to see whether she was actually ready to be discharged, or had any sort of support system at home.
That's why I took over as her caregiver 10 years ago. By default the system assumes family or friends will handle all post-op care. They don't actually bother to determine whether any family, friends or pre-arranged post-op care system exists. It's just an assumption.
Care manager? Social worker? There are none in some county hospitals and public hospitals like ours.
Originally Posted by
HillRiderEast
You said your Dad had Kaiser. My guess is he is with them via a Kaiser Permanente Medicare Advantage Plan. The advantage plans provide Medicare benefits and then supplemental benefits picking up out of pocket costs patients have with Medicare like inpatient deductible and coinsurance. The Kaiser people or the hospital discharge planning people really fell down on they job. They evidently felt he was stable enough following his surgery and did not send him to a skilled nursing facility for a couple of weeks for post acute care. In the Medicare advantage plans with the government, the health plan is at risk for the cost of care. The plans try to save money on things when they feel services are not necessary such as a skilled care. Again, they screwed up because your dad had a re-admisssion and they hate these kinds of occurences - does not make sense, because they did not arrange care after his first discharge in a way to prevent a re-admisssion. All these plans have nurses called Care Managers - their role is to identify patients at risk for re-hospitalization and then keep track of them very closely either directly with the patient or the family to make sure all medical needs are met, appointments are made and kept, prescriptions filled and prescriptions taken correctly. Call your dad's primary care practice and ask to be directed to the Nurse Care Manager in the practice or the health plan that follows high risk chronically ill patients. They should already have your dad red-flagged for intervention. Good Luck and your are a good son to be there for your dad.