Question (by e-mail): Our father (78) was recently hospitalized with heart and lung disease. After being moved from intensive care where he was in bed for ten days, the doctors began talk of discharging him back home. This concerned us greatly because (1) he is unable to even get out of bed by himself, (2) our mother (also 78) has been struggling with a debilitating lung disease and is incapable of providing care for him, and (3) all three children live in other states. In talking with the social worker who was assigned to our father, we were told that since Medicare would not cover hospitalization, if he stays any longer, he and my mother will be charged for the care - which is well beyond their means. They are talking about home health for a short period of time, but this does not answer our dilemma.

We are not experts, but we think that our family is being treated very shabbily and that the economics of being required to pay for is being used to force us to take Dad home before he is ready. Is there anything we can do?

Answer: Because of the way in which Medicare operates, the discharge planning process is most important, and can be most complicated. Experts tell us that the discharge planning process should begin as early as possible in order to avoid the situation where discharge is imminent, and the family does not know the available options.

In a nutshell, the Medicare-certified hospital in which your father is a patient is obligated to provide him with a smooth transition to the most appropriate place for post-hospital or rehabilitative care. A discharge planning evaluation can be initiated by your father, you as his representative, or his doctor. The hospital must schedule the evaluation in a timely fashion.

Once developed, if your father is not satisfied that the plan provides for the most appropriate type of post-hospital placement, he or his representative can complain to the hospital administrator, the state inspection agency, or the Peer Review Organization. While Medicare does not provide for any specific remedy or right of appeal, if the complaint is that the discharge is premature, the patient does have a special right of appeal to the Peer Review Organization.

Because of the way in which you describe your father's condition, the question becomes whether rehabilitation services are reasonable and medically necessary to allow your father to function as independently as possible before being discharged home. Rehabilitation can be accomplished either (1) in the hospital in an area of lower level of care sometimes called "Transitional Unit" which is like a skilled nursing facility, (2) in a skilled nursing facility, or (3) on an outpatient basis.

In order for Medicare to pay for rehabilitation services in the hospital, (1) your father's doctor must certify that inpatient hospitalization for rehabilitation is medically necessary and that your father needs a relatively intense multidisciplinary rehabilitation program; (2) the rehabilitation program must be provided by a coordinated multidisciplinary team; (3) the goal of the program must be to upgrade your father's ability to function as independently as possible; and (4) the care must be provided in a Medicare certified facility.

While Medicare Part A covers "extended care services'' - that is skilled nursing and rehabilitation services -- in a skilled nursing facility, Medicare does not pay for custodial or personal care -- help with daily needs, such as bathing or eating.

Because the level-of-care requirements for skilled services under Medicare Part A are extremely restrictive, most nursing home residents receive either limited or no Medicare coverage for their stay. To qualify, the services must be so complex that they can only be safely and effectively performed only by -- or under the supervision of -- technical or professional personnel, such as registered nurses. Under Medicare rules, the determinative factor is the patient's need for the services, not the potential for restoration.