Advocacy in Health Care. Helping a Client Transition from the Hospital with Mark Asch, Right at Home

Philip Fish, CFP<sup>®</sup> and Estate Planning Specialist with Sandy Spring Trust

A Real Life Matters Discussion Series.

In these discussions Phil Fish, CFP® and Estate Planning Specialist with Sandy Spring Trust interviews local professionals in the areas of law, tax, finance and health care on topics focused around helping families navigate through life’s stages. Phil has worked for Sandy Spring Bank for over 20 years and has over 30 years of experience in the financial and estate planning industries.

Guest Speaker:  Mark Asch with Right at Home. Mark has been with Right at Home for nine years and has worked in the health care field for over twenty years. Right at Home is a licensed home care agency serving Montgomery County, Prince George’s County and parts of Baltimore.

In this discussion Phil and Mark discuss the challenges a client and their family can face as they try to transition from the hospital after a medical event.

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    Advocacy in Health Care. Helping a Client Transition from the Hospital


    - Hello everyone. And welcome to Sandy Spring Banks Real Life Matters discussion series. Thank you for joining us today, as I interview professionals in the areas of law, tax, finance, and healthcare on various topics revolving around trying to help clients navigate through their various stages of life. I'm joined today by Mark Asch with Right At Home. And before I introduce Mark to you, there is a brief disclaimer that I do need to read. So provide me a few moments if you would. Sandy Spring trust does not endorse or recommend the services of any person or entity not affiliated with Sandy Spring Bank. The opinions and statements expressed by Mark Asch and Right at Home, reflect their own view and do not necessarily represent the views of Sandy Spring Trust. This material is provided is solely for educational purposes by Sandy Spring Trust and is not intended to constitute tax, legal, accounting or healthcare advice or recommendation for any investment strategy or transaction. You should always consult your own tax, legal, accounting, financial, or healthcare advisors regarding your specific situation and needs. Sandy Spring Trust and the Sandy Spring Bank logo are registered trademarks of Sandy Spring Bank. All rights are reserved. So thank you for that housekeeping. Mark thank you for joining us today.

    - Phil it's a pleasure. Thanks so much for having me.

    - We've got an interesting topic today. It's advocacy in healthcare, how to help a client transition from the hospital. So why don't we start if you can give our audience a little background on yourself and the company that you work for Right at Home and how you've kind of gotten into this line of work and then we'll walk into the discussion of today's topic.

    - I'll be happy to. And Phil, thanks so much. And it's an honor to work with you. It's an honor to work with Sandy Spring Bank. I've been in healthcare field now for more than 21 years. It's my second career. I spent many years in hospitality management and Phil, I got into healthcare because I realized that in the hospitality world, I wasn't helping people enjoy a better quality of life as I could have been. Specifically as it relates to living optimally as they age and was raised in sort of a nursing home setting. My grandmother ran a kitchen at a nursing home in Baltimore, where I got some Hebrew education and in fact was involved in synagogue services at the nursing homes. Starting young, I was immersed in kind of that environment but I didn't get into healthcare until about 2000, where I started in the field with adult medical day programs, opening and running adult medical daycare. And I learned that it's a great way to help people stay safe and well, they want to live at home and they don't have to go into a long-term type of care setting. In addition, Phil, I worked in a skilled nursing capacity as an admission director, and then I came to Right at Home where I am now. I've been with Right at Home now almost eight and a half years. And Phil, you mentioned Right at Home and what do we do. Phil Right at Home is a non-medical home care agency. We provide non-medical care whether it's episodic. So if someone's had a, let's say a hip replacement or a surgery or ongoing care and support. If a person can't take care of themselves as well anymore. So we provide the non-medical care anywhere from a couple of hours up to 24 hour care. The agency I represent Phil, we cover Prince George's County, Montgomery County, and parts of Baltimore.

    - Okay.

    - I'll touch on what non-medical home care is in a little more detail .

    - Sure in my role, as we were chatting earlier, I mentioned as a trust officer for a number of years, my role for the trust division is I'm an estate planning specialist, and a certified financial planner. I'm basically a problem solver. So I do a lot of public speaking and this series kind of developed from, we had a kind of an educational group of professionals that met and then COVID came along. And so we had to kind of figure out new ways to stay connected with the community. And so we're actually gonna be developing the discussion series and building out a library of content where I interview lawyers and accountants and healthcare professionals. But very early on, as a trust officer, I realize that I was not the right person to provide medical advocacy to clients. I started to connect with medical advocates like the individuals in your firm. And I realized the importance of trying to help and guide clients through these very difficult transitions. So I think today we're gonna be talking about a hypothetical case study that you and I will be discussing about an individual in a hospital setting and you and I, before we started recording, talked about how it's so overwhelming for families to-

    - Absolutely.

    - Illness of a loved one. They might not even have family by, it might just be they might be on their own. They might be sick. They might be scared. Or the individuals that, you know, a spouse, a son, daughter, brother, sister, they might not be local. They might be trying to help, but it's so confusing, so why don't we go through, you know, a scenario of how you know, you and your firm and others in other lines of work similar to yours, are positioned to provide guidance for individuals during that difficult time.

    - Absolutely. So I appreciate that. And the program that I developed is called advocacy in a health crisis. And Phil, this was born out of a conversation I had with an elder law attorney and a gerapsych nurse many years ago at a health fair. We talked about the fact that no one discusses the topic of advocacy, and we wanted to come up with a way that we could educate the public on what advocacy is and how it works. So we created this case study. This is all fictitious, no protected health information is presented here. And the idea of the case study Phil is that we can carry the conversation forward. And this is very common. This happens frequently to families where they don't even try to learn about the healthcare system until there's a crisis. And Phil, I can tell you, that's not the best time to learn about the healthcare system, especially as complex as it's become. So we present today, a woman named Sally, and for all intents and purposes for this conversation, Sally is a widow. She's a widow of a Korean war veteran and she's in her upper seventies and she lives alone. She presents at the hospital with what appears to be a stroke. She's had a stroke. And you know, when we look at this situation especially when someone's had a stroke, first and foremost there has to be quick action. There has to be rapid response. Her caregiver or emergency personnel have to know what's going on, have to know that she needs treatment right away to have it addressed. But often in a stroke, a person cannot represent themselves or speak for themselves. So we look at two things whether a person can advocate for themselves, Phil, or whether they need someone to speak for them. And so in this case setting, we're going to talk about how Sally is going to need an advocate, someone to speak for her. And so I want to preface this by bringing up a conversation that you and I have had in the past. And it was about having the conversation. Phil like you and I talked about families are often afraid to have the conversation of God forbid what would happen to me, if I ever get sick. And you know, that's not a conversation that anyone should be afraid of. The best thing to do is to sit down with your family. First, you sit down and you think to yourself how would I want to be treated if God forbid I ever became sick. And you ask yourself that and you make notes on paper, and then you sit down with your significant others and your loved ones and you discuss, this is how I would like to be treated. This is what would happen if I go to the hospital, God forbid, this is who I would like to speak for me. And then you appoint a backup person in case that first person can't speak for you. And then as we're gonna discuss through this presentation, you set up some documentation, legal documentation that allows your advocates to be the proper voice for you and Phil, that's critically important. It's critically important because when someone is of the right mind and they know what they want, they can put these things on paper and protect themselves. And remember how Phil we talked about how this unburdens the family. You mentioned how so many families come to you and they're ill prepared. And sometimes they come to you after a crisis has occurred, which is too late. And you can unburden your family if you have this conversation in advance and then set up some documentation like we'll talk about and prepare yourself for a better outcome and better success.

    - Yeah, we found a similar issue on the financial side, and I've done these discussion groups and interact with professionals in law, tax, finance, healthcare. There's a common theme is there's a huge difference between a proactive and a reactive approach is that if we can, you know, on the financial side, I do seminars which are available on our website to view on financial and estate planning. And the conversation is very similar to the one you've just had. It's the importance of having the right documents in place, of having conversations with your decision-makers in advance, both for legal issues and financial and tech and healthcare. And so, but it is hard. It's hard for parents to talk to a son or daughter about . A lot of times the children don't want to engage, because they don't want to imagine their father or mother not being there, not being healthy. So I think our challenge in our industry is to encourage clients to be a little more proactive, not wait for the event, because it always works out better if we can have the conversations that you've talked about in advance.

    - Absolutely.

    - Okay so let's go back to Sally and continue our conversation for sally.

    - Absolutely. The first thing we look at is whether Sally is of the capacity to speak for herself. A person is of the capacity to speak for themselves when they understand the medical situation that they're in, and they have the acuity in the moment to make decisions to forward their health treatment. So they can speak for themselves. They understand what's going on and they can speak for themselves. This is important in that if a person has advancing dementia or other illnesses, which don't allow them to understand what's going on, the documentation I'm gonna speak of should have been put in place in advance just as you described. So the first situation is whether Sally can speak for herself, she understands what's going on and can make decisions to advance her medical situation. That's called capacity. She has the capacity to design for herself. In this case for the presentation, Sally is incapacitated which means in this situation, she cannot speak for herself nor can she properly represent how to move her health forward or make decisions thereof. So Sally needs to have an advocate. So, to decide who the advocate is, like I said, it should have been done in advance and then you have proper documentation. So there's three documents that you would put in place to speak to that. First is called a healthcare power of attorney. And this could be an episodic situation. So if somebody is having an operation, they would set up something for someone to speak for them during the operation, or this could be ongoing. If someone is failing in health, they would have an ongoing healthcare power of attorney. This is the document that you should definitely see a legal professional for, because they can properly guide you on how to properly set it up to make sure it's effective for every situation moving forward. And I always advise that. The second document is what we call the advanced directives. The advanced directives are those questions that we should have addressed in that earlier conversation, Phil, is how would I want to be treated if I became sick. Do I want them to cut into me for emergency purposes? Do I want tubes in my throat? Do I want to be plugged to equipment? Many people for religious or personal beliefs don't want to be connected to that type of equipment. So you can spell that out in advance. Your advanced directives would do that. In the state of Maryland, we have the MOST, it's called the Medical Order for Life Sustaining Treatment. MOST is something that a person-

    - This has caused lots of confusion in the people that I contracted with because they were used to the medical advanced directive. And then this new form came out. And like, you know, does this replace the form? How does this work? So how does the MOST fit into the right pattern to the list?

    - MOST is more of a standardized presentation and the MOST should be reviewed with the patient and their primary care physician is who should review the MOST with them. And the primary care physician is the one who should certify that with the signature that they've had the conversation on what sort of life-sustaining measures that a person wishes. You know, advanced directives are still recognized. And, especially if they're properly documented and certified, that's important. The MOST form is more of a standardized approach to it. Now every situation may be different for where certain places don't accept certain things. So again, this is not the answer to everything, but in a general sense, that's the way that you should approach it. If you can get the MOST done, do it.

    - On the financial side, in Maryland, we have the statutory form which is a kind of standard financial form for financial advocacy during an illness. And then a lot of lawyers will also create a more personalized, financial private attorney that may get into a lot more specifics and do some, you know, unique planning strategy. So it sounds like it's a little similar to having a standard form. And then one that has a little more, you know, options for creativity. But again, I guess with your example with Sally, unfortunately if she had not completed these forms and she entered the hospital and being incapacitated, she's no longer legally capable of stating her wishes. And so what happens in that situation now that we've got Sally here, you know in the hospital needing advocacy, but she hasn't taken care of that proactive approach. She hasn't like, because if she had, and if these documents were on file with her physician and her family knew where they were located. They could walk into the hospital with those forms and state "I am the medical agent for my aunt Sally. Here's the documents. I'm now representing her." And they could step into that role of advocacy. But I think in your example, Sally hasn't been proactive. So, now what happens?

    - Well, we don't assume whether she has or not, but that's a great point. You know, you bring up a couple of great points, Phil, first of all, Sally and everyone else should always keep a copy of those important documents, including her prescription. She should always keep a copy of those on her refrigerator in her home. If Sally, God forbid, is picked up by emergency personnel, emergency medical personnel, they know to look on the refrigerator to see if she has a copy of this documentation that they can take with them. Now it's important to also, you know, have a certified copy, maybe digitally or a paper copy that a person carries with them. Or if you know your local hospital file that information in advance in the event of an emergency. So it's critical. That's why it's so important to have the conversation ahead of time and this way hopefully these things can be alleviated. The other piece of it, of documentation, that a person should have is the HIPAA form. The Health Information Portability Act protects a person's private health information. So if Sally goes to the hospital and Sally has five kids and Sally has two friends, the hospital doesn't have to talk to those five kids or two friends, unless there's a document, a HIPAA authorization form allowing the hospital to talk to anyone who was authorized by Sally to talk about her health condition. So Sally should also again, have a HIPAA authorization form for each person who's going to advocate for her. This is another reason, you know, we talk about outcomes, Phil. If you put all this documentation in advance and I had a situation a couple of years ago in Bowie, Maryland. We were in the senior center, we were doing the same presentation and a woman raised her hand and said "I have all this documentation, but my one adult son isn't willing to carry out my wishes." So in this case we recommended having a friend who's gonna advocate for her and then having a backup who also understands her wishes or hiring a professional firm to act as her advocate. And in both cases, she's protecting her wishes, not the wishes of her family. So for those people who come from large families, you could have seven people in the hospital with seven different ideas of how mom would want to be treated. And that's never a good idea for the best outcome in this case for Sally. So we always want to focus on the best outcome for the patient, and that's why it's better to have it in advance and have one person speaking your wishes and one person carrying that on.

    - And the worst thing to have is if you have individuals of similar status, say children and disagreeing the hospital and the medical staff were put in an incredibly difficult situation, because Sally cannot communicate. There aren't clear documentation stating who should we go to? So if Sally had the documents stating Julie is the person I want you speaking to, she's my agent, then the hospitals have direction from the client say, okay, Julie and Sam are arguing, but Sally named Julie in her documents. So we're going to talk to Julie because she's been given, so if we don't have that clarity having, because when families, when we face illness or death, it's so hard on a family. It really pushes things to the extreme and families that were getting along fine can be fractured and really go through a rough time. So when I'm counseling clients about the importance of proactive planning, which is what we do at Sandy Spring Trust. It's a huge part of, you know we're focusing primarily on the legal financial side, but the medical side has to be a part of that conversation is our goal is for the decision-makers not really to be decision-makers but to be individuals who are going to carry out the wishes of the client and the client says, this is what I want done. I'm not asking you to choose that. I'm just asking you to honor my wish. And we stress the importance. We want the decision-maker to know that they're not choosing a certain path, especially if it's restricting you know, ongoing medical care. It's to state "This is my wish. Will you help me honor my wish? Will you ensure that the hospital follows my wishes?" And now it's not really a decision maker. It's more somebody who's going to be an advocate as you talk about-

    - Absolutely because you know what, it's each person they're representing that person in the hospital, that each family member and so on and friend or whatever the case, they may be. They all have a different opinion and a different ego about what they can do for that individual. When you document and plan for a crisis like this, you take all that burden and worry away, not the worry or the care, but it's about the best outcome for in this case, Sally, or the person laying in the bed. And then there's, you know, there's also always a financial consideration Phil and people think, well, when I get to be 65, Medicare is gonna pay for everything. I'm gonna go to the hospital. I'm gonna be treated like a queen or King and Medicare is going to pay for everything. And that's another place where the bubble might burst. We've learned dramatically across this country and across the world, really the high cost of healthcare especially if we're not ready for it. So many people through the pandemic have been hospitalized. Some for months, some have perished, unfortunately, but there's a tremendous cost involved. And Medicare is not there to pick up every bit of cost and everything. So it's incumbent upon a person and I'm not gonna get into Medicare because that's a completely complex issue, but it's incumbent upon each individual to understand what their medical insurance is, what it covers in a hospital situation and what it covers after a hospital situation. I do want to bring up one thing about the hospital. Several years ago the hospitals used to see patients and then that patient would leave and come back a week later for the same illness, and it was happening over and over again. And so Medicare created a rule, a look back rule, to see if a hospital had, I'm sorry, not to look back rule, but to see if a hospital had treated the same patient within a certain period of time. And Medicare recognized that people were being treated for the same thing over and over and over again. So Medicare created this rule where they said to the hospital, that if you treat a person within a certain period of time over and over for the same illness, then we're gonna dock you against your Medicare. We may not even pay for the care for that individual and the third time or the fourth time. So the hospitals created this little loophole if you will, called observation versus admission. So if a person goes to the hospital in this case, Sally, she may be in a hospital bed a couple of nights and then be sent away, she's out of the hospital, but she may not have been an admitted patient into the hospital. She may have been what's called under observation. When a person is under observation, if they have to go to another phase of care, like a rehab center Phil, Medicare may not pay for that person to go to a rehab. You may have to pay out of pocket to go to a rehab, which is more than $600 a day. Phil, you may know some of your clients, who are able to finance that, but the majority of people aren't able to finance more than $600 a day of a rehab. So that's why you have to understand your insurances, what they cover in the hospital and what they cover after the hospital. Again, I don't want to get into the Medicare because that's a complex conversation.

    - I think that it is, and I think that's where my experience with medical advocacy groups, you know, like your firm and others can be so valuable because you understand the system and you can guide the client. And it might be something along the lines of talking to Sally's family and saying, well let's make sure she gets admitted because we need, you know, we need to talk to people and they need to check the box admitted. It might be simply just getting somebody to say, okay, yes we'll move her from observance to admitted. But then that, because it's like playing a game of chess. You're kind of looking three moves down the line saying if we can get her to this point, then we can get her to this point. And the insurance you currently have will cover if we go down path A, but if we go down path B, we're gonna have a $5,000 bill on our table in three weeks time. And so that's where that having somebody in your corner with knowledge, because it's not fair to expect the general public to understand these, we struggle. I mean, I'm not a healthcare expert. I just hang around healthcare people and pick a few things up along the way. But even the experts in healthcare struggle because it's so complex. And you've got hospitals, and you've got billing you've got Medicare, you've got supplemental insurance. And every plan is a little different. And if the client's on this medication that's covered, but if they get a different kind of medication that their insurance plan doesn't cover they've got an $8,000 prescription bill, because the doctor prescribed the medication that their insurance wouldn't cover. But something that does the exact same benefit, one lane over would be fully covered. And that's why people get so frustrated with the system I'm afraid.

    - Absolutely because, you know, so I always tell people it's important to understand what your insurance is, what the coverages are, what the limitations are in this type of situation. And so hopefully one of the things that comes out of our presentation today is that someone does look into their own situation. Now, Medicare is a medical insurance. So it's going to cover medical necessity, just like your other medical insurances. In addition, if someone qualifies for Medicaid medical assistance, that works the same way as Medicare in most situations. But again, you have to understand what your coverages are and what's going to be covered in the hospital with the hospital stay and what's not. And whether your stay is a qualifying stay. Usually Phil it's three midnights in the hospital.

    - Okay.

    - Is a qualifying stay in order, if you had to go to a rehab after the hospital. In this case, Sally would have to go to the rehab after the hospital because she's had a stroke.

    - Sure.

    - There may be several issues that will come up that need to be addressed in a rehabilitation situation. Sally has her qualifying stay in the hospital. She can go to the rehab and the first 20 days are covered at a hundred percent under Medicare. The first 20 days are covered at a hundred percent. From day 21 to day 100, there's a copay and it's based on 20% of what the daily rate is in the skilled nursing center. So right now the copay is about $160 a day or maybe a little bit higher. So often if someone gets to that 21 day point the rehab might go on a month in advance. So you have to know these things and plan in advance 'cos no one I've ever met has a stack of money. Maybe you have clients Phil, but no one has a stack of money that they just want to give to a rehab, you know and say, "Here care for my loved one." And so in this case, also, as I mentioned earlier Sally is a widow of a Korean war veteran. So there might be veterans pension benefits or other veterans care benefits that she qualifies for, which may pay toward other types of care after she gets out of the hospital.

    - And I think that the challenge that we face is Sally, first of all, may not have anyone to be an advocate, you know, depending on the family structure where the family, is there family, where's the family located. Does the family even know Sally's in the hospital? Sometimes it's a case that, you know she's just kind of, you know, they haven't caught up to the news yet. And so, you know but if there is family, their, you know, significant other, their mother, their sister, somebody who's really important has had a stroke. So the last thing they're thinking about is is she gonna be admitted for three midnights? And they're dealing with the immediate crisis of mom's sick or my wife's sick, and you get this, you know, you're just lost. So you know what, we, in our line of work, when we work with clients and we do a lot of work talking about transition planning, planning for transition, planning for life stages, changes and having plans in advance is obviously as we mentioned, having the right legal documents, the wills, the trust, the powers of attorney, the medical advanced directives, have the decision-makers know where they're located, be able to access them quickly, maybe having a copy with the primary physician or the local hospital, you know, copies I believe are okay in Maryland. So having your family member have a copy so they can get quick access, but then having that advocacy point, you know, firms like yours and others engaged where Sally's daughter knows to call your firm or the other firm, the other care management firm that they're working with to say, okay, I'm supposed to call Mark now, or Julie or Sam, who I've already met when mum was healthy. And mum told me if there's a medical emergency call this number, these are kind of the guardian angels, who can then come in and talk to the doctors understand the gibberish that is the medical world of all this terminology, and then ask the right questions of the doctors or the nurses saying, you know have you thought about this? Have you thought about this? What about this? You know, no, we don't want to check Sally out 'cos it's 11:45 at night, which has only been here for two midnights. Can we check her out at one o'clock in the morning? It might be that, one hour difference could be thousands of dollars or tens of thousands of dollars in difference.

    - That happens and you know, there are a tremendous number of the actual, there are professional advocacy firms now that just strictly do advocacy that I work hand in hand with. I work with a care advocate and they coordinate all and help all, you know there's also what they call aging life care managers, which used to be called geriatric care managers. And they can be the eyes and ears for that family to coordinate all the different pieces including the care advocacy and so on. And so, yes, we're an important link in that chain. And I try to help every family I can by connecting them with the resources that may be necessary. And the point you just made is great, because this people don't understand as well. When you described how the hospital may want to discharge. And this goes into skilled nursing center as well. The hospital may want to discharge your loved one before you have all the pieces in place for the next level of care, the next phase of care. That's called an orderly discharge, excuse me. Every patient in the hospital and every patient in the skilled nursing center has the right to an orderly discharge. So you have to have the pieces in place for your next phase of care, in a reasonable sense. So the hospital can't discharge you at midnight, if the next phase of care isn't set up, that's inappropriate. And yes, you as an advocate for that patient can speak up and say, "Listen this is not the way it's going to happen." And there's some complexities, but if a person has to go to a rehab from the hospital and they have to go at midnight, the rehab the next day may not have the medications that person needs until later in the day. And so there's complexities regarding the medication and other things, Phil, and again that's another complex issue that I don't want us to go down the wrong rabbit hole. So let's look at Sally for a little bit and understand that Sally's had a stroke. She may have problems speaking or vocalizing. Her processes may not be connected. She may have problems with her bodily functions. She may have lost use of one or both sides of her body, of her limbs. So she will need rehabilitative care. She will need rehabilitative services, but while she's in the hospital, those services can start right away if the family understands what her care wishes are and work toward those better outcomes. And that's why having that advocate is most important. And I want to speak to that point for a second as well, Phil, because the best thing an advocate can do is maintain the calm, understand Sally's wishes, and understand how to get the best out of that team in the hospital. And the way that they get the best out of the team in the hospital is by understanding who is in each boat. You know Phil, back when you and I were kids, if God forbid one of our older relatives went to the hospital, their family physician came to see them in the hospital and coordinated their care. So this doesn't happen now at all. In the hospital, there are physicians and specialists that are strictly physicians and specialists in the hospital. In the general term it's called a hospitalist. And that is a physician that strictly works for the care of a patient while they're in the hospital. So if you can imagine this situation, Phil, Sally's just coming in from the outside, this hospitalist who's gonna treat her in this case, it's gonna be what they a call criticalist, a person who's gonna take care of someone in critical care. The criticalist may have never met Sally before or not know her health condition prior to coming in. They may not know her allergies or medications or any of that situation. This is why it's so important to have the documentation in place and to have an advocate in place, who knows this information that can help the physicians work toward the best outcome for Sally. If not, Phil, the hospital is going to go on their basic standard of treatment based on what they're seeing in front of them, which may or may not be Sally's wishes.

    - Yeah or that might be an allergic reaction to certain medication or a special, she might have a heart issue that is not readily, you know recognizable.

    - Absolutely.

    - We always keep coming back to a proactive approach, you know, having an advocate, a plan, conversations, communication knowing what documentation is kept for the advocate to be able to get quick access to medical records, so that they can be shared, you know. We're not quite in the world I don't think where somebody can click a button and suddenly access everybody's medical records. I think there's been a lot of improvement with access, but, you know, and Sally may just be visiting from out of town. She may not even be local. So in our next, I'd like to wrap up in the next five, 10 minutes. So as we talk about, you know, Sally, obviously we've talked about the huge difference between Sally being in the hospital on her own without advocacy or even having family members around her, who may either not have the legal authority to be an advocate or may not be positioned with the knowledge of what Sally's wishes are to be an advocate. But if Sally does do this proactively and if there is an advocacy component in place, it might be a family member working with somebody like the professionals you have or others to support, what are some of the next steps for Sally, as we look at you know, you talked about rehab, which is, I think kind of a stepping stone from the hospital to maybe a longer term solution.

    - Absolutely that's a great point. So, you know, assuming that that the advocate communicated well with the hospital staff and that they're working toward the best outcome for Sally, in this case, Sally would go to, and it's possible she would need an acute rehabilitation center, which is often the hospital itself has an acute rehabilitation hospital within their confines, they're based on what her care needs are directly. In most cases, that person is gonna go to a subacute skilled nursing center, which is a skilled nursing center in the community which can provide that subacute care the follow-up care to the stroke, and she may need, the first thing they're gonna look at is speech therapy. Speech therapy is going to deal with chewing and swallowing issues, as well as helping if a person gets an aphasia from the stroke, helping that person recover their ability to speak, talk, and process. So if a person is in need of receiving therapies, they're gonna receive those therapies in the rehabilitation center. And then they typically are going to stay, like I said, some stay 20 days or less, some stay longer based on their medical and their support need. So if they've been in the rehabilitation center and then they want to discharge home they can go home with what's called skilled home health. Skilled home health is covered by medical insurance, as long as the physician in the hospital or the rehab center writes the medical order for skilled home health. And that would be an agency that can continue the therapies at home for Sally. In this case physical therapy, occupational therapy, speech therapy and so on. In those cases, again, it's important Phil, for each person to understand what their insurance covers while they're in the rehabilitation center and once they come home and then what services are available to them. So the next aspect that they look at is their activities of daily living. Eating, bathing, dressing, toileting, and mobility. And Phil, if a person needs assistance with those types of things in addition to having the home health agency come in and do the physical and occupational therapies, they may also need a caregiver to come in and help with those aspects. I just described the activities of daily living. So they can hire an agency like ours, Right at Home, where a caregiver and Phil, I just want to point out our caregivers are bonded and insured, properly vetted and trained employees of our agency. They go through a vetting process. We are screening them for health right now. They're tested weekly for COVID. We always want to keep our caregivers safe and our clients, clients and client families. So that the caregivers can come in and can provide, if the client just needs some mild supports, that's called companion care. If the client needs hands-on assistance with their hygiene and so on, which most stroke patients would in this situation, the family could hire a caregiver from our agency, our agency to provide a caregiver that can support that person at their level of need. And then we can also help with taking medications and so on and so forth. And all personal care and medication administration is supervised by a registered nurse. So that person always has a resource like us, that can help with those difficult things at home. You know, it's important that that family is able to maintain their family relationship. It's an important and tangible fill and having care come in. So families can also receive under their insurances, they can receive things like what's called durable medical equipment, where if a person needs a hospital bed at home, a person needs a raised toilet seat or a walker or a wheelchair. So again, those things are mainly covered under that person's insurances and it's important for each person to learn what their insurance coverages are, what's necessary and how to make the home safe. There are people that you can hire Phil now to come in and assess the home to determine how to make it safe. There are agencies that can come in and make modifications to the home to keep it safe. And making sure that a person can age well in place is critically important. So I mentioned earlier, geriatric care manager, aging life care manager, a family can hire that type of person make sure all the facets of care are working in conjunction. And then if a person just can't live at home anymore, there are things like assisted living resources and things like that. Again, a person should be aware of their finances and should be aware of what their insurance coverages are. So, you know, after looking at all these pieces, though I think it's so important to wrap up just to remind everybody how important it is to think of these things in advance, address these wishes on paper while a person has their wits about them, and to set themselves up for success, before the situation turns into a crisis situation. And again, I'm Mark Asch with Right at Home. Phil, I appreciate you, you know taking the time to have this conversation with me and, you know, I can be available to anyone that may have questions regarding some of the material we covered. Phil, do you have any questions that maybe things I didn't touch on. I know I briefed you on some of the last bit of information.

    - I did not. I think our contact information will be on the exit screen at the end of the day's presentation for Mark. Thank you, Mark for your time and your knowledge.

    - My pleasure.

    - One of the reasons we're doing these programs and for the audience, thank you for joining. My name is Phil Fish. I'm an estate planning specialist and a certified financial planner with Sandy Spring Trust. I've been with the bank for over 20 years. I'm basically a problem solver on the financial and estate planning side. So I do the work very similar to Mark's team on the medical side working on the estate and financial planning side with portfolio managers and trust offices, estate planning attorneys that we work with. Many of them you'll see you through this discussion series as we provide this information. and one thing you'll now notice is the audiences when you clicked to view today's presentation there was no registration. You did not have to enter your name, your email address your phone number, any of that. We wanted to set this up as purely a community bank service. Sandy Spring Bank has been around for 152 years. We've been standing by our client's side since 1868 and we're now the largest local community bank. And for the past 20 years it's been an honor to be a member of this bank's organization. And I'll continue to work here through my retirement years. I'm not sure when that will be, but it's just fun and a pleasure to work for this organization. And so please spread the word about the discussion series to family, friends, coworkers, locally and even non-locally. We're gonna be have speakers as we build the library out in law, tax, finance, healthcare, people like Mark and others. Just trying to get you to stop thinking about how to manage navigating through life stages. And if you have more questions, feel free to reach out to Mark or myself. And also I host estate and financial planning seminars on the Sandy Spring Bank website. If you go and click on Wealth and Trust and click on Seminars, you'll find a number of seminars scheduled for upcoming months but also recordings of previous ones that you can watch. So I hope you'll, if you want to hear me speak for a little more on financial and estate planning issues, hop on over to that side of the website, and we'll talk about wills and trusts and investments and mutual funds and protective trust and all of that kind of information. So, Mark thank you again for your time.

    - It's been my pleasure. Stay bold and stay safe.

    - Thank you. Now on behalf of the community, thank you and your staff for the work that you've done, especially during these difficult times with COVID. You're on the front line and I know it must be difficult and stressful. So on behalf of the community, thank you for the work that your staff does, working with clients and trying to keep them safe. So take care of yourself. And for those of you watching today, have a wonderful day, take care, and if Sandy Spring Bank can help in any way please let us know, have a wonderful afternoon.

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