Mike Day 62: A Fresh Start

April 21, 2011

Family, Health, Mike

After a good bit of crying over the outcome of the Highmark appeal yesterday, I had a revelation.  I realized my thinking on the whole topic of this brain injury pre-authorization was directionally incorrect. I was pretty much delusional in hoping Highmark would reverse their decision on these appeals in any reasonable fashion.  

I was being naive I think.  I believed that we were deciding on a medical issue…something having to do with a person’s well being…something akin to appropriate treatment and medically necessary treatment as their denial letters said. I believed they had my husband’s best interests at heart.  I realized I had lost my objectivity and become far too personally invested to see the big picture.  (Can you believe it?  Lost my objectivity where my husband’s well being and future were considered!  How could I ever have let that happen???)

What I realized is that I was thinking like a human being.  A wife.  A friend.  What I needed to do was think about things from Highmark’s perspective.  I had to think about their goals in this…what was their stake?  Well.  Obviously,  they are invested in their own self interests not Mike’s or any other patients best interests.  And they hold the power over my life and Mike’s in the stroke of their little keyboard.  They have legal teams that have churned out meaningless and euphemistic denial letters that spin words around whether something is or is not medically necessary and justify with all ilk of words how something is not appropriate without ever citing a single concrete reason why.  In the end, after reading their denial letters, you feel like you are a sombrero laying on the ground and Highmark has just danced the Mexican Hat Dance all around you.  Clearly, I needed to think like Highmark and not like Mike’s loving wife in order to be able to circumnavigate their nonsense…to be able to play their game.  I think I’ve figured it out.  It’s so simple really.  I just have to be mindful of their (unstated) goals that are identical to any other corporations and understand their rules…or find out what the rules of the game are.  Armed with that, circumnavigation and playing the game should be simple.

I think I’ve hit upon it.  We’ll see.  At least I’ve developed a strategy.  (or a hypothesis as the scientists might say).  Let’s see how it plays out.  But bottom line…I’m definitely not going away.  I’m not lying around licking my wounds either.

We’ve been following Highmark’s rules of the game and working to find a suitable nursing home for Mike.  I prioritized the list of network providers and we’ve either asked their liaisons to come in or given them chart info if they have no liaisons.  Of the first six contacted, four have declined on the basis of trach and mitts.  The two with liaisons visited Mike and me yesterday.  They were number one and two on my list based on rating and prior experience of a friend or friends.  I think the first may decline…they have no respiratory therapist so they typically don’t take trach patients.  We’ll see what they say.  From a proximity perspective they would be best. 

The next has some very attractive features…therapy 6 days a week.  No problem with the trach.  No problem with the feeding tube.  No problem with size or size of bed necessary.  Vital Stim therapy to help resolve Mike’s swallowing reflex issue.  Bringing their Director of Nursing and Director of Therapy to see me today so I can question them without having to leave Mike.  Commitment to continue to work toward getting him ready to meet Highmark’s requirements (whatever they might be) for admission to brain injury rehab and continuing to apply for admission to it for us.  The liaison was pretty shocked, after meeting Mike and looking at his chart, that Highmark was not approving for brain injury.  He said clearly brain injury rehab is what is required.  (Hello?  Do you think Highmark??)  He isn’t sure about the mitts and the four siderail requirements and needs to check with his Director of Admissions.  If they are a go, pending a site visit, I think I could like this place if I had to settle.  A church member was there after a stroke for the vital stim therapy and said the care she received was excellent.

Meanwhile, yesterday the PT and OT folks from the brain injury program came to the specialty hospital to evaluate Mike for the hospital appeal to Highmark.  They found him to be totally appropriate.  Today the specialty OT dept will do a complete ADL (Activities of Daily Living) eval and documentation for it.  Mike will also visit the PT gym today. 

Yesterday Mike started to realize when he needs to void…and used the urinal.  A huge step…he can recognize what’s going on with his body.  Seems the physical activity is starting to rewire his brain…or time…or both…and he is becoming more aware of himself, his circumstance, his place. 

He told me he wanted to “Get the hell outta here” and when I asked to go where?  He said “Home.”  I told him I wanted to get him out of there too…but we needed more therapy for walking and swallowing first.  Next he wanted to know, “How the hell did I get here?”  I asked if he remembered going to Lehigh Valley Cedar Crest with me and needing a cardiac cath?  He said yes.  I explained he had a heart attack, needed a ventilator, got pneumonia, had some setbacks with sepsis and internal bleeding but now was recovering.  He looked quite shocked when I said he had a heart attack…but I thought it was important to tell him honestly while he was asking.  He said “But how did I get here?”  I explained he had come here to Good Shepherd for ventilator weaning.  He asked for my jalapeno cheddar crackers.  I explained since he couldn’t swallow well yet he would aspirate, get pneumonia, have to stay here longer, and Theresa, his Speech Therapist would kill me if I did so.  Three times he begged.  Three times I told him the same thing.  He told me, “You’re full of shit.  Get the hell out of here.”  He meant it at the moment.  I was delighted to see him intelligibly stringing full sentences together in spite of the aphasia even if he was cussing at me. Next he wanted to know where Zolly was.  (Zolly is his buddy, our Vizsla).  I really must get the vet form signed and take the two V’s in to see him now that he’s asked.  When Mel called to say the priest would be coming to the hospital in the afternoon today for anointing and I told her it might help with this devilish attitude…explaining his antics, she concluded we needed an exorcism instead. 

Then, at sundown, Mike ventured into the land of confusion, agitation and restlessness.  Back into the mitts early even though I was in the room.  Sedated…it did some, but not much good.  Seems the more stimulation and awareness Mike develops the more frustrated he is becoming with his surroundings and the more confused he becomes in the evenings.  Seems this is very common with brain injury patients.  I hope it is very, very transient.  I feel like he is suffering and it kills me to watch it. 

Well, today is a new day.  The sun is out.  My magnolia tree is in glorious full bloom.  And I’m off to the hospital to see what’s up on this new day.

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