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My 91-year old mother is being released from a rehab hospital tomorrow. After 2 and 1/2 weeks of rehab and 5 days of hospitalization before that, she really isn't any stronger functionally. Her symptoms initially appeared to be a stroke, although the CT scan found no evidence of that. As I understand it, she has blockages in her brain and her brain is shrinking. She has dementia (no memory; lives very much "in the now"), she eats & drinks very little (ongoing battles with UTIs and dehydration), and she is incontinent much of the time. She can still walk with assistance and can transfer from chair to bed with the help of one aid and a PT belt.

The rehab doctors recommend that we return Mother to her apartment which is nearby our home. They believe she will have a better quality of life there than in a skilled nursing facility. My mother is very sweet, compliant, and really isn't any trouble other than assisting her with dressing/body functions/meals, etc. She happily sits in her recliner with her cat in her lap, reading or watching TV. She still has a sense of humor; she just has no memory and is confused much of the time.

I have no delusions about Mother getting better, but I hope that we are able to keep her out of the hospital so that she is able to eventually die at home. Mother has limited financial resources, but there is money enough for a home care person in the daytime (at least for a year or so), and I or my husband will stay with her at night.

Here are some of my questions:

The rehab doctor will send us home with some temporary home health care. Are there medical services that will come to her apartment to check for dehydration and UTIs? How do I locate those?

Mother has no terminal diagnosis, although I suspect she is moving into a "failure to thrive" situation. Can her regular primary care physician who is most familiar with her medical history make that diagnosis? Will that diagnosis enable us to get hospice assistance?

Are there other questions I need to be asking or other issues I need to be considering? I'm new to this forum, but I've been poring over it for information on handling incontinence, etc.

Thanks so much for any help you an give me. Blessings on all of you!

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195Austin, you went through quite an ordeal. I'm going to look into the Phillips lifeline. We've been told Mother should have 24-7 care, but the reality is there are going to be an hour here or there where she will be alone. We are fortunate that she isn't a wanderer; she is pretty cooperative about staying in her chair once she gets into it. The life alert would be another level of security.

Thanks for the insights on Medicaid. This is helpful!
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The rehad should have at least one social workers and since most rehabs are located in or next to NH the social worker should have seen her on day one of rehab if get in touch with her in NY the social workers do all the planning for medicare home care like meals on wheels and you are given the name of the home care agency and they should talk to you about a hospital bed she should definatly have one of those necklace or wrist alert systems I have Phillips lifeline which the equitment was free and I pay 39 dollars a month and they call my son as well as the medics. We in my county now have VNS Visiting Nurses Service but before that we had a local hospital home care and the Department of health that set up PT and whatever other services they need. She will probably do better at home-if she was on medicaide she might get longer services but not always-they promise more help but if they do not have the staff -you do not get what you need-so do not let them tell you if on medicaide she will be covered 5 days a week becaude it just does not happen -if you do apply for medicaide let the social worker help-that application is a killer-I actually broke down crying in the social worker's office when starting it for my husband-who died suddenly while I was working on the application-it is so complacated because in the past rich people were able to get it who should not have gotten it so they dot the I's and cross the t's now-either that or get an elder lawyer to help-you will have to pay a retainor but it is worth it in the long run. If you have anymore questions go to my wall-I became a unwanted expert-the husband was in rehad at least 16 times during the last few years f his life and I dealth with two nursing homes-the one he usually went to turned him down because he was too demanding so I used another that I liked better and their social worker did not have a drinking problem and was not as old as sin like the one closer to us had as a social worker who I found out after the fact she was only working in the social service office and was not even a social worker-I did get an education and learn to be strong during that ordeal.
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2much2cover, thank you for this information. We have the bedside toilet and other items, but the information you gave on services (transportation, in-home care, 211 help line) is exactly what I need! Thanks again.
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If you think she would qualify now or in the near future for any Medicaid or nursing home diversion programs which will cover some in home health aide, incontinency supplies, meals, etc. you should look into that now. Start with your state internet site and search for their dept or agency related to aging, elderly, seniors. Does your community have a 211 help line where they can refer you to services?
Before discharge ask the dr to write an order for in home physical or occupational (or even speech if applicable) therapy if you think she would benefit from that (the quality of in home therapists vary but if you get a good one willing to work the patient can benefit). Also ask for an order for in home nurse visits covered by Medicare, who can monitor patient with visits. Look into what in home dr visits are available, like a mobile podiatrist, dermatologist. some communities even have drs that make house calls covered under medicare. Does she need a hospital bed which can help with safety with rails and suport while sitting up in bed or elevating legs. would she know how to use an emergency alert button (even if never left alone, you never know when it might be needed. I had an aide who passed out on a couch. If on medicaid incontinency supplies could possibly be covered, Medicare would also cover a bedside commode (which also could be used to elevate the toilet and provide handles to assist in getting up.l possibly. Make sure the bathroom is safe with a bath seat, grab bar, etc. If she has to get to appt with an aide, you could also look into your community and medicaid programs for transportation programs for disabled and elderly.
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