Today I cried over a patient.

Today was a tough day. Today, I lost the battle in the ongoing war of insurance vs therapists (and other healthcare professionals) that ended up negatively impacting patients. Of course this could be only obvious to myself and other therapists as I am sure both patients are excited to return home. It started with a patient that has been here a little over 2 months. History: suffered a stroke, while only being at another SNF for 2 weeks aspirated and went back to the hospital for pneumonia and was there quite some time. I remember reading how he and his family both insisted on getting rehab. I also remember the OT and I walking in there like “no way is this patient appropriate for therapy”. From being extremely hard of hearing and not able speak to maximum assist of 2 to sit edge of bed, oxygen saturations dropping easily, no trace of muscle activation in his stroke affected side, and somewhere in the 2’s for non-affected side lower extremity strength. The OT and I were just like his oxygen saturations are unstable, it takes 2 of use just to maintain his sitting balance… he is not appropriate at this time, there is no way he could even want therapy. But, we asked him multiple times if he wanted therapy and he gave us thumbs up every time. It was not always pretty. There was groaning out in pain… and not just from the patient. We put him through the ringer. Oxygen tubes got pulled by accident, water sprayed through the nasal cannula with him still attached, toes were stepped on, and I KNOW he hated the Russian stim. All that being said, we grew to love him and he progressed. Progress was very slow to start and sometimes minimal, but we saw it. Speech really worked with him and he was able to start conversing with us and joking with us more. Some days, he didn’t want to participate and those days were HARD on our bodies as the therapists when trying to work on sitting balance (he would really push back whenever initially sitting up without back support, and man were those trunk extensors STRONG when he push back). 

To him, I was “Julie”. Not sure why he was stuck on that name, but I went with it. He would always wave me in late in the afternoon “Julie, when ya gettin’ off, I need a ride home.” He even called in a different therapist that looks similar to me (but we all have facemasks now) and would be like “Oh, you’re not Julie… tell her I said hey.” The joke with the other therapists was “Julie can do no wrong”, which was a running joke since the oxygen line and toe stepping was usually mostly caused by me. Today, his insurance nomnicked him and we lost the appeal. We were so disappointed. Just the other day the COTA and I discussed his progress and the potential of being able to get him standing with less assist. I get it: the progress was slow and minimal and “not functional”, but damn it my job is to make people stronger and increase mobility and we were doing that! Function was going to come. Oh his lower extremity strength? Just increased from 2’s to 4 / 5 and his paretic leg increased from no trace activation to 3/ 5 TELL ME THAT’S NOT FUNCTIONAL PROGRESS. We were finally getting into upper and lower extremity weight bearing ideas.

Today, he waved me in and asked if I spoke to his son yet (he asks me this most days. Always wanting me to let his son know he isn’t coming home that night). This time, I called and we both spoke to him. Before leaving, the patient said “I want to be honest with you about something, and I don’t want you to think I’m trying to flirt with you. But I really grew to love you. I am so thankful for you and everything you did for me. I’m going to miss you.” I’m tearing up again just typing it. I told him the feeling was mutual and ran out of there before tears could leave my eyes. 

Here is the very short and less emotional story of the next patient. This patient appealed TWICE. Before I even knew his insurance denied further coverage, I wrote how he continues to make progress but is not at his prior level of function and is UNSAFE to go home. Apparently, insurance took that as “Okay, so he’s going home tomorrow.” He was even making more steady, significant, and consistent progress compared to the patient above. I just couldn’t believe it. Today, insurance won the battle. Tonight, I will cut my losses, have a drink (or more than one), and continue the fight for my patients tomorrow.

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