Social Services

  • Robert Goodman, MSW
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Your Right to Appeal
Your Right to Appeal 150 150 Robert Goodman, MSW

Your Right to Appeal
The Savvy Senior
By Robert Goodman, MSW
 
Being a good health care consumer means knowing your rights and advocating for yourself. Whether you are applying for or currently receiving services you have the right to appeal if you disagree with a coverage or payment decision made by Medicare, your Medicare plan, Social Security, or any government agency. Different programs and services have different procedures for appeals. The time allowed for appeals also varies. HMO patients also have the right to appeal adverse decisions.
Hospital patients have the right to appropriate care and appropriate discharges. A person cannot be discharged into an unsafe environment, such as being sent home where they cannot take care of themselves or no one is available to care for them.
A Medicare beneficiary has the right to appeal a hospital discharge if he or she feels too sick to leave. A hospital will provide “An Important Message from Medicare,” which explains how to appeal the discharge. Medicare beneficiaries can call Florida Medical Quality Assurance, Inc (FMQAI) at 800-844-8754 for an appeal. FMQAI staff members will look at the medical record to see if the beneficiary should stay in the hospital. The beneficiary will be informed of the decision. The Medicare beneficiary does not have to leave the hospital. The Medicare beneficiary does not have to pay for the extra days in the hospital while FMQAI staff members review the medical record.
A Medicare beneficiary has the right to appeal a discharge if he or she does not agree with the discontinuation of skilled services (skilled nursing care, hospice, home health care). The beneficiary must be given a letter with the planned discharge date explaining how to appeal the discharge. Once the beneficiary receives the letter, he or she can call FMQAI at 866-800-8768. An FMQAI physician will look at the medical record to see if the services should continue. The Medicare beneficiary will be informed of the decision.
If a Medicare beneficiary is in an HMO, he or she has some additional Medicare rights. If the beneficiary feels he or she cannot get the needed care, he or she has the right to appeal to the HMO. The Medicare beneficiary can appeal things like denials for: referrals to a specialist, approval for tests (like x-rays or blood tests), or payment of a bill.
The HMO has information about how to start the appeal process. A Medicare beneficiary who feels he or she may get worse by waiting too long can ask for an expedited appeal. This means the HMO must make a decision about the appeal within three calendar days. A Medicare beneficiary who needs an expedited appeal must be sure to ask for it.
If a Medicare beneficiary has a concern or is not satisfied with the quality of care received, he or she can call the FMQAI Florida Medicare Beneficiary Complaints Helpline at 800-844-0795. You may also download a quality of care complaint form English or Spanish to complete and fax to 813- 354-0737, or mail to: FMQAI, 5201 West Kennedy Boulevard, Suite 900, Tampa, Florida 33609, Attention: Beneficiary Complaints.
The above information is from www.fmqai.com and www.medicare.gov. For more information on your right to appeal a Medicare related decision call 800.MEDICARE (633-4227).
 
Here are ten steps to help you become an effective self-advocate:
1. Believe in yourself
2. Realize you have rights
3. Discuss your concerns with your service provider
4. Get the facts in writing
5. Use the chain of command to solve a problem-ask to speak to a supervisor if an issue wasn’t resolved to your satisfaction
6. Know your appeal rights if services are denied
7. Be assertive and persistent, not aggressive
8. Outline your concerns and be a good listener
9. Ask for help from other agencies
10. Follow-up. Be sure you’re getting the service that meets your
needs…and say thank you
 

  • Robert Goodman, MSW
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A Neighbor Needs Help
A Neighbor Needs Help 150 150 Robert Goodman, MSW

A Neighbor Needs Help
By Robert Goodman, MSW
 
Perhaps you know of someone who can no longer take care of him/herself and has no one to help. Or perhaps you know of someone who is getting inadequate help. The question you need to ask is, does this person pose a danger to him/herself (or others)?
 
We all want to live independently for as long as we can. The idea of going into a nursing home is a horrible thought. Even assisted living is not considered a viable option by many. Families don’t want to institutionalize their loved ones. An aide 24/7 may not always be the best answer. So what do we do?
 
First, we are our neighbor’s keeper. If you suspect a neighbor is having difficulty taking care of him/herself you may want to voice your concern to a friend or member of the family. If no one is taking responsibility and that person is in need of help you can call a local social service agency or call the state abuse hotline (1.800.96.ABUSE). You can call anonymously.
 
Here are some indicators that there may be a need for intervention:
1. APARTMENT:

  • Garbage piling up in the apartment.
  • Hazardous living conditions due to lack of repairs, utilities and/or equipment
  • Human excrement on floors and furniture
  • Evidence of obvious fire hazards, such as piles of boxes, newspapers, old clothes, blocked exits

2. FOOD AND CLOTHING:

  • Little or no food in the house
  • Food is spoiled or lying around
  • Insufficient/inappropriate clothing for the weather

 
When calling the Florida Abuse Hotline to report personal neglect (or abuse or exploitation),be prepared to provide the following information:

  1. Person’s name, address or location, approximate age, race and sex;
  2. Physical, mental or behavioral indications that the person is infirm or disabled;
  3. Signs or indication of harm or injury or potential harm or injury (physical description or behavioral changes);
  4. Relationship of the person responsible for the senior’s care, if known. If the relationship is unknown, a report will still be taken if other reporting criteria are met.

 
The Department of Children and Families will conduct an investigation of all reports received that alleges self-neglect by a vulnerable adult. The purpose of the investigation is to determine if there is evidence that a person is a danger to him/herself, and if assistance is necessary to protect the individual’s health and safety.
 
A protective investigator from the department will make face-to-face contact with the vulnerable adult within 24 hours of receiving an abuse, neglect or exploitation report. The protective investigator will interview all persons who may have knowledge of the victim’s situation, evaluate the information obtained, and make a decision as to whether the reported allegations did or did not occur. The investigator then refers the case to an agency for follow up so the victim can get the services s/he needs to be safe. This may include placement in a more suitable living environment.
 
Remember to report abuse, neglect, self-neglect, or exploitation call the Florida Abuse Hotline at 1.800.96.ABUSE. Help your neighbors who cannot help themselves.
 
We Care has a telephone reassurance and friendly visitor program for those who are homebound. To volunteer or to refer someone call 487.2827.
 

  • Robert Goodman, MSW
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Aging in Place
Aging in Place 150 150 Robert Goodman, MSW

The Savvy Senior
By Robert Goodman, MSW
 
As we grow older (not me!) our first choice is to remain in our homes for the rest of our lives. How many of us develop a plan to “age in place”? Just like you plan for college or retirement, we must also plan for the years beyond retirement. Aging in place refers to a person’s desire to remain in their own home and receive services, if needed, in their home or community. To successfully age in place one has to plan for the physical and mental changes that may occur as we age. This may include modifying your living space.
Several professionals can help you plan for your future. These include elder law attorneys, financial planners, health care providers, home accessibility consultants, for profit health related companies, and non-profit organizations.
An elder law attorney handles general estate planning issues and counsels clients about planning for their incapacity. The attorney would also assist the client in planning for possible long-term care needs, including nursing home care. An elder law attorney can help you locate the appropriate type of care, coordinate private and public resources to finance the cost of care, and work to ensure the client’s right to quality care. There are many elder law attorneys in our area. Ask any attorney if he/she is certified in this field. To locate an elder law attorney contact the Academy of Florida Elder Law Attorneys at www.afela.org or 850-656-3038.
A Certified Financial Planner (CFP) is someone who is specially trained in personal finance.  To become licensed Certified Financial Planners must have demonstrated competency in seven important subjects: the General Principles of Financial Planning, Risk Management and Insurance Planning, Employee Benefits Planning, Investment Planning, Income Tax Planning, Retirement Planning, and Estate Planning.  These are the areas one would need to consider when planning for long-term care expenses either immediately or in the future.  CFP’s have been subjected to a background check and must also have demonstrated experience before becoming licensed. Select a certified financial planner who specializes in Medicaid, VA benefits, and elder care planning. Be sure to ask any prospective planner if this is their area of expertise. To locate a certified financial planner contact the Certified Financial Planner Board of Standards at www.cfp.net or call 800-487-1497.
Writing a living will and choosing a health care surrogate are important steps to take while one is healthy. A living will lets your doctor know what steps should be taken or not taken in the event that you cannot communicate your needs. A health care surrogate is a person you appoint to make decisions regarding your health care in case you are unable to. These forms are available at most hospitals or by going online to Aging with Dignity at www.fivewishes.org or calling 1-888-594-7437.
Safety is a major concern in the home as we age. Good lighting, use color contrast, eliminating throw rugs, and installing grab bars are all things that help make the home safer. There are home accessibility specialists that can help you determine what is needed in your home to make it safe and easier to use should you become disabled. Contact the Center for Independent Living Options for a referral at 561-966-4288.
As part of the planning process you may want to select a home care provider now who can provide you needed services in the future. You may also want to look at housing alternatives, such as an assisted living facility or nursing home if the need arises. www.floridahealthfinder.gov is a great website aid in locating all kinds of health care facilities.
 
 

  • Robert Goodman, MSW
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Medicare and Home Health
Medicare and Home Health 150 150 Robert Goodman, MSW

By Robert Goodman
Home Health Care and Medicare

Medicare covers home health care services for someone meeting these conditions:

  1. Your doctor must decide that you need medical care at home, and make a plan for your care at home.
  2. You must need intermittent skilled nursing care, physical therapy, speech-language therapy, or to continue occupational therapy. 
  3. The home health agency caring for you must be approved by the Medicare
  4. You must be homebound, or normally unable to leave home without help.

If you meet all four of the conditions above, Medicare will cover the following types of home health care:

  • Skilled nursing care
  • Home health aide services
  • Physical therapy, speech-language therapy, and occupational therapy
  • Medical social services
  • Certain medical supplies
  • Durable medical equipment
  • Medicare does not cover homemaker services like shopping, cleaning, and laundry; and
  • Personal care given by home health aides like bathing, dressing, and using the bathroom when this is the only care you need.

There are several types of home care providers. Only Medicare approved home health care agencies are covered by Medicare. Private pay services include nurse registries and companion services. There are some private pay home health agencies that provide the services listed above.

Companion/Homemaker: Services include companionship, errands, escorts, meal preparation, and homemaking.
Home Health Agency: Recruits, screens, and hires their staff as employees. Services include home health care, skilled nursing, physical/occupational/speech therapy, companions, homemakers. May provide 24-hour live-in aides.
Nurse Registry: Recruits, screens, and refers aides, who are independent contractors, to clients. Services include nurses, respite care, home health aides, companions, homemakers, and 24 hour live-in aides.
 
There are many different types of personnel who may be handling your care. Besides therapists and social workers there are different types of home care workers who may come into your home.
Companion/Homemaker May do the following: Prepares/serves meals, does housekeeping, and accompany client on errands/trips. The Companion/Homemaker must have some training in topics related to human development and interpersonal relationships, nutrition, marketing, food storage, use of equipment and supplies, planning and organizing of household tasks, and principles of cleanliness and safety.
 
Home Health Aide (HHA) In addition to the services provided by a Companion/Homemaker, a HHA may provide “hands on” personal care, which includes assistance in the activities of daily living, such as bathing, grooming, dressing, personal hygiene, eating, and assistance in physical transfer and ambulation. Some HHA’s can be trained to supervise medication. Most HHA’s have a high school diploma, although it is not required. To work for a Medicare or Medicaid home health agency, a HHA must complete 75+ hours of training or successfully complete a competency evaluation given by the home health agency.
Certified Nursing Assistants (CNA) provides the same types of services as the Home Health Aide, but the CNA is certified by the state, a high school or G.E.D is required, and typically receives a higher rate of pay. The programs are 6-12 weeks in length and include “hands-on” care giving experience.
Licensed Practical Nurse (LPN) provides services such as monitoring vital signs, preparing and giving injections, enemas, help in evaluation of the needs of the client, and supervising nursing assistants and aides. LPN’s can also be involved in teaching and training family members in simple nursing tasks. LPN’s must go through a State-approved Nursing Program.  
Registered Nurse (RN) works to promote health, prevent illness, educate patients and families, and develop/manage nursing care plans. RN’s are educated in the science and theory behind the care they are administering and supervising. The RN assessment involves a more holistic approach to evaluating the patient, making sure both their physical and psychology needs are being addressed.
For more information log onto www.medicare.com/hhcompare
 

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  • Robert Goodman, MSW
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Locating & Accessing Community Resources & Services
Locating & Accessing Community Resources & Services 150 150 Robert Goodman, MSW

The Savvy Senior

By Robert Goodman, MSW

Locating & Accessing Community Resources & Services

 
“I need help and I don’t know where to turn!” Where would you begin to look if you needed help for a loved one? There are many government and community-based services available to assist older adults; people with mental, developmental, or physical disabilities; and caregivers. Finding them and accessing their services is often where the difficulty begins. How do I begin the search?
 
The first step in looking for services is to organize your or your loved one’s records. These include:
1. Personal Records
2. Legal Documents
3. Medical Records
4. Health Insurance information
5. Financial records
 
Step two is to add all your sources of income to determine your monthly income.
Next add the total value of all your assets.
 
Step three: Determine what kind of help the person needs:  EDS
Make a list of the things the person can or cannot do and who is available to help, with what, and how often.
Can the person:
__ Take medication on time and in the correct dosage
__ Go shopping for food and clothing
__ Visit friends or drive a car
__ Travel by bus or taxi
__ Do light housekeeping
__ Do heavy housekeeping
__ Do the laundry
__ Afford to pay the bills
__ Write checks and pay bill efficiently
__ Take care of legal matters
__ Maintain personal cleanliness
__ Get dressed
__ Use the toilet
__ Sleep through the night
__ Safely use the stairs & outdoor steps
__ Look up telephone numbers and make calls without help
__Be safely left alone
 
WHERE DO I FIND THE SERVICES I NEED?
1. Internet (do a “Google” or other search engine search)
2. Library
3. White/Yellow Pages
4. Information & Referral/Crisis Helplines (ie, 2-1-1)
5. City/county/state/federal government
6. Area Agencies on Aging
7. Hospital social work/case management departments
8. Community health fairs/expos
9. Religious institutions
10. Referrals from friends, relatives, and colleagues.
 
WHAT DO I DO AFTER I HAVE LOCATED A PARTICULAR SERVICE?
Once services are located, it’s important to learn about the services and how they can address the needs of the person who needs help.
A valuable place to learn about services prior to making phone calls is to visit the agency/organization’s website. Read through the services and information described and take notes. The information you glean may be enough for you to know this agency or program isn’t what you’re looking for or on the other hand, it may sound like a perfect match. Narrowing down your choices this way without having to make numerous phone calls saves a lot of time and energy. Doing an internet search also provides prior knowledge about the agency, which is very convenient to have in advance of placing a call to them.
Although some services and programs can be applied for online, others should be contacted by phone.
 
PRIOR TO CALLING AN AGENCY FOR SERVICE
1. Determine your goals: What services does the person need? Be clear about the services you’re looking for by putting your goals and questions in writing.
2. Make a list of agencies you want to call.
3. Have your previously organized records near the phone for reference. Having quick access to answers will save you frustration, time, and money.
4. Have a notebook and pen ready for taking notes—don’t use small scraps of paper that could easily be lost. Do role playing to calm nerves.
 
CALLING THE AGENCY
A Sample Script
“My name is ________. I am caring for ________ who is my ________. I need ________. The hours I need this help are ________. Can you help me?”
If the answer is no, ask “Can you give me another name or agency to call?” If the answer is yes, ask“What services do you provide? What are the costs and how are they paid? Eligibility requirements? How long must we wait to get services? Can you send a brochure and application? What is your website address? Can you do an intake over the phone? To whom am I speaking? Do I need to speak to anyone else?”
 
Tips When Speaking with the Agency
1. Try to call in the morning.
2. Describe exactly what you need, when you need it, and any limitations you may have in paying for the service. Ask about services, fees, eligibility requirements, waiting lists, for their website address , and to send you a brochure.
3. Interview the agency; ask lots of questions. Determine by their demeanor and response if this would be the appropriate agency to fill the need.
4. Call several agencies to compare.
5. Keep good notes, including the name and number of the agency, the person you spoke to, additional phone numbers and/or email address, website, questions and responses, and names and contact info of additional agencies you were referred to.
6. Enlist the support of those you are calling; don’t put them on the defensive.
7. Be persistent and patient—it may take many calls to get the services you want.
8. Be assertive—call back and ask for a supervisor if you are not satisfied with the answers or advice. Document date, time, and contents of call, and file a complaint with appropriate funding agency, better business bureau, or chamber of commerce.
9. If denied services, ask how to appeal. You have the right to a written decision.
DENIALS AND APPEALS
 Make a log of all correspondence and phone calls regarding denials. Include dates and names of people. When did you receive notice of the denial? How did you receive notification of the denial? Who notified you directly about the denial?
 Most programs and insurance plans have a formal grievance procedure. Get the procedure in writing and follow through.
 
ONCE SERVICES ARE APPROVED
1. Develop a detailed file: name/contact info of agency, description of service, referrals of other services needed.
2. Follow up to be sure the services are appropriate and are being provided for in an efficient and effective way.
3. Document any gaps in service or prob-lems and follow up with agency to resolve problem.
4. If gaps of service are due to budget or other cuts, advocate before your elected officials. 

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