I'm now medical power of atty for my friend who had a leg amputated due to diabetes complications and who has been in one of the most highly recommended nursing/rehab centers in the area for the past two weeks. She needs to be evaluated by a neuro for significant cognitive issues, and a pain specialist as well as for unrelenting neuropathy.

We have been told that we cannot make appointments with outside doctors for her, that all requests have to be okayed by the facility's house doctor. The head nurse told us that they had forwarded her records to a pain clinic a week ago, but the clinic has not responded. They say there is no need to have a neuro. eval. until her pain is under control, and I have to agree that her mental status is severely impacted by her pain level.

Back to the house doc (who only comes to the center twice a week) having to okay all referrals--is this standard in nursing facilities? What would happen if I just notified the facility that I was doing so, and went ahead to make appointments? I would of course give them ample notice of when the appts. were to take place.

I'm most grateful for any suggestions on how to proceed. The policy just doesn't seem right to me.

I hope Johanna C. will see and respond.

But nope, I'm not aware of any circumstances under which this is their unilateral decision.

Patients (and their POA) have the right to consult additional doctors anytime they want to.

I think just doing it is an excellent plan, although it may affect who pays for the consult if it's not made subsequent to a referral.

Have you spoken to the administrator about this?

I've only gone as far as the head nurse with this, as she is the portal through which we are to make these requests to the house doctor.

I have been working on a fax to send to the Director of Nursing, the social worker and the head nurse as soon as I can get to a fax machine tomorrow (I live out of town). I can certainly add the administrator to the list.

In the meantime I'll keep checking back to see what others can suggest.

Thanks!

Elizabeth, when our Grandpa was in the NH we used the "house doctor", and he did indeed "take over" those aspects of Grandpa's care. Grandpa only had one specialist, and by the time he was in the NH, it really no longer mattered because he declined so very quickly.

The Director of Nursing told me that the facility considered it to be "coordination of care", and that way they could make sure that everyone stayed on the same page as far as patient care/quality of life issues/etc. were concerned.

This particular NH was funded by a church, and non-profit. I don't know if that matters a bit, but it could be that certain "types" of NHs handle things a certain way?

I don't think legally they can prevent you from seeing other doctors. They may want to keep the money "in-house" but that is their problem.

Call your insurance company, the Obmudsman, etc. Residents have rights -- they are not prisoners.

This really depends upon your friend's insurance. You can only have one Primary care Physician (PCP) at a time for most regular health care plans and Medicare. When people are in NHs, their PCP is the House Doctor for good or bad. Medicare and some insurances are sticklers for that and require referrals. If your friend has a gold plated high end health care plan, then she can go out to any specialist without referral.

Thanks for the great information, everyone. Yesterday we put our complaints/questions in writing and took it up the chain of command, from the head nurse to the administrator. My friend worked in local government for 30 years, so she's used to battling bureaucracies, and she got a kick out of using some of her old skills despite being in significant pain.

I'm happy to report that we made some great progress:

1) The director of nursing is going to bat for us with the pain clinic to get an appt. a.s.a.p.;

2) In the meantime, the house doctor has doubled one of her pain meds;

3) The DON and administrator are reviewing the specialist referral policy in light of the fact that my friend's insurance does not require her to be referred by a PCP.

Again, thanks for your tips and support.

I was gonna say, "like he** you can't!" I'm about to find a dermatologist for Dad because of some unresolved skin issues. He's had a lot of skin cancers from his years of ranching. He's got a puffy spot on his face that won't go away altogether, comes and goes, and a spot on his nose that isn't healing. I will have to take him, but it's well worth it. He has a derm. that he's used there before in Glen Rose to have a mole removed from his arm last winter.

Lammie is right on!!! They can't stop you to go outside with other specialists to treat your LO.

In our case mom had her own doc outside, but for our own sanity of not having to drive her to all docs, we chose to go with house doctor. I did this after researching the doc and speaking with others at facility for their opinion. When she first met with doc she (new doc) called me to tell me about mom and what she saw and thought would be next. She only recommended and asked since I've got POA to agree with her or suggest other options for mom's care. Then when schedule for tests, they called to tell me outcome of tests. This new doc suggested a psychiatrist, which also comes into facility. This doc called me too after the analysis and recommended a few things. Didn't just state this is what we're doing, but we suggest this and do you agree. If agree we'll go forward.

What I'm telling you here, YES YOU HAVE CONTROL AND NO FACILITY SHOULD OR CAN TELL YOU WHO CAN HANDLE YOUR LO HEALTH CARE. Go outside facility for another doctor if don't feel comfortable, as I surely would.

Best to you

Jazzy1 -- regarding that psych evaluation -- I'd make darn sure she sees the doctor. Some of them just send in the nurse practioner who relays the info back to the doctor. I could do that.

I would say you want to be there -- and you can get there pretty much at the drop of a hat -- as they will tell you they don't have a schedule, etc. Tell them you don't want to be in the room, you would like to be there to talk to the doctor face to face. Gives you a chance to see if they caught mom on a good day or a bad.

The one night I was not at the NH is when he supposedly came...I would not bet any money on it, though.

Hello Elizabeth:

I am sorry I was gone for awhile, I was out ill for a bit.

No, a nursing home cannot keep you from making appropriate physician appointments for your loved one.

I was wondering if they wanted their MD to ascertain whether or not their patient was physically stable for going out of the facility to a clinic/doctor's appointment. That would be the only thing I could think of that would warrant a NH doctor to be involved.

If you run into any more speedbumps, I would contact the Ombudsman Office in this facilities area immediately.

As for the pain clinic, you do NOT have to wait for the NH to handle things. You can call the pain clinic and interact with the staff there to glean a better understanding as to what is involved and how they plan to accommodate your significant other. I always do this for my loved ones; it is surprising how much I learn this way and how much I can shorten the process.

A Neuro consult does sound as though it would bring positive things to the table; but I think you are correct. Until the priority issue is managed, (the pain), it will fog the Neuro exam. Of course, increased pain medication may also increase changes, but once stable, you can determine the course you wish to take with Neuro.

Good for you in taking concrete action regarding what appears to be a VERY unfortunate policy at the facility. Hopefully, this is the end of that issue.

Please let us know how things are going, we will certainly be thinking of you.

I wish you the very best in all of this,

Johanna C.

Your responses have been so helpful. I'm grateful to each and every one of you.

The day after we submitted our written request to the rehab facility, our LO was sent to the hospital with a sever UTI. She was ready to be released with a Pick (?) line, but the rehab place's doc denied her readmission! At first he said it was because they were afraid she would be allergic to the antibiotic (she does have many allergies); then said that they could not administer drugs through the Pick line. That was pure BS, but there wasn't any way we could appeal a "medical" decision.

It turned out to be a blessing in disguise, though. We found another rehab place, and the differences in attitudes, attention, and willingness to discuss (and listen!) to concerns regarding her care are simply dramatic. After a relatively brief period of adjustment, our friend is now settling in, her pain is better controlled, and we are all breathing a great sigh of relief.

I know this can change in a heartbeat, but now we have confidence that the staff will respond quickly and appropriately. And yes, we can make outside appointments as needed. Hooray!

When one door closes, another opens. Prayers that things continue to settle down for all of you!

Dear Elizabeth: I am very happy that things took a turn for the better. What a huge relief this must be.

Let us know how it is going. We are thinking of you.

Johanna C.

Talk about blessings in disguise.

Nhs can be officious at times, and that is where our role as advocate comes in. As I told the DON once, "I did not abdicate my mother to you when she moved in!"