A couple of months ago I received a call from a lawyer asking that I do an assessment on a woman who had been deemed ineligibile by Medicaid to stay at the assisted living facility where she lived for the past 3 years. The State claimed she was no longer medically eligible for community Medicaid (MLTSS). Susan, her sister-in-law Brenda reported, had had emotional, mental and medical difficulties from childhood and needs to be in a supportive environment and this judgement was a departure from the decision Medicaid had made 3 years earlier deeming her eligible.
The Medicaid representative stated that Susan was able to care for herself, based on nursing notes and interviews with Susan, who assured her that she was quite independent and perfectly able to bathe herself, take medications properly, ambulate without assistance, maintain her diet and be involved in activities.
The problem was that the nursing notes were inconsistent and sometimes contradictory due to a change in staff and lack of coordination. In addition to my assessment and seeing the lack of a full history of Susan’s development, I recommended that a neuropsychological exam be administered.
Our task was to be neutral, to read the nursing notes but also take into account the observations of family and staff who knew Susan well. They reported a decline and were concerned about her memory functioning. Staff presented a consistent picture of a 68 year old woman who had social and emotional issues and would bend a truth to get what she wanted. They all observed that Susan had become more dependent as evidenced by her refusal to take medications properly saying, “the nurses know what pills I take, I don’t have to”; follow a diet for diabetes, irritable bowel syndrome and weight control; refuse to follow recommendations from physical therapy to help with poor balance and gait; and the need for an aide to assist with bathing to avoid the rashes she was getting from poor self-care. In addition, they noted, Susan had been isolating herself socially, not attending programs she used to enjoy and having meals delivered to her room – an extra expense to the family were it to continue. They all reported that Susan’s memory was spotty and noted an inability to learn new tasks (like the TV remote which she had been familiar with).
I met with Susan, who presented as alert but talking for even a few minutes revealed a person with limited insight and significant gaps in logic and memory. She exhibited overlearned behavior; i.e., knowing the “right” thing to say but not comprehending that it was in fact harming her. The neuropsychologist, through testing and interviews, concluded that Susan “suffers from a developmental disability since birth, which has had profound ramifications involving severe deficits in adaptive functioning.”
As a team we agreed that releasing Susan to a community setting would be a disaster and that our reports would support keeping her at the assisted living. After all, with poor social skills and an inability to care for herself, how could she possibly manage?
At the same time, the lawyer tackled the legal side – working with the facility to rectify the nursing notes and reflect the changes staff had reported but hadn’t recorded, then integrate that with our test and interview results.
It felt like a miracle was in order but no, it was skill, not magic, that lead the state to re-evaluate their findings. A coordinated and well documented picture compelled the state to change its determination.
As Brenda said in a note to us “There is no question that your assessments and perseverance played a significant role in getting Susan placed in a level of care that allows her to stay where she is. Working with all of you gave us the energy to rally through this. Thank you for your professionalism and support.”