They're talking about discharging my dad from his SNF next week. He'll be around the 30 day mark. So nurses keep saying "he's doing really good" and the PT keeps talking up progress. I believe the nurses (save for one amazing one) are generally basing that on his refusal to take his pain meds. Maybe I'm a skeptic. The PT contacted my mom and I to come doing some walking with my dad yesterday and "talk about some things."

These "things" turned out to be a maybe discharge date.

The walk went very badly. He's using a walker, but I don't think he's using it safely because he's hunched over it, he's tripping on the legs and on his own feet, and it was like he was chasing it. The PT valiantly, idiotically tried to talk up how "good" it went and how he was "stiff" but some times are better. I should say that the PT recommended I or my mother would almost always need to grab the waistband of his pants to help him stand, stand sideways beside him with one arm looped through his, and walk that way with him.

This is how they want to send him home, because he could "walk" from his room to a common space maybe fifty feet away.

Then when we expressed that we had concerns, he promised to wow us with stairs today. (Spoiler alert... more concerns came from that.)

Before the PT left yesterday, he tried to sell us on "he's pretty good on 3 stairs... I know you said there are 5 to the bathroom but... he could use a urinal or commode 'for awhile'" and that sort of thing. My mom asked how it's 'for awhile' could happen, could improve, when he'd basically just made my dad homebound to the first floor of the house.

He suddenly had somewhere else to be.

The stairs went badly today, the PT did not have my dad walk for us today. The PT did reluctantly admit that yesterday went badly, but did try to be rosy on everything. Except, not so rosy because he also said part of the reason we should be okay with discharge is "he'll still need help at Christmas" and "if he's worse in January, ask for in-home PT."

He suddenly had somewhere to be when my mom asked how he knew my dad wouldn't improve more, need less help at Christmas if he did more work there.

But, long story short, in the time I have been telling my story here, I have learned so much. I have learned to be guarded when I answer questions from a PT about what I can and will do. I have learned to spot someone trying to shoo me out the door and I have learned to stand my ground. I have learned about 'improvement' therapy versus 'maintenance' therapy and that we can appeal three times. I have learned about Jimmo and about ombudsmen and that plateaus are something from the past a reason to send someone away.

So while I am so sorry for the things you all have gone through, I hope you know that the things you have shared are so important. I will pay it forward however I can. Thank you.

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No clue why they are not suggesting LTC. Does dad have the funds to private pay? LTC insurance? Do they accept Medicaid?

I'm with Rovana 100%.............WHY are they wanting to send dad home when they can keep him in long term care??? What are we missing here? Makes no sense.

BarbBrooklyn is right...............go talk to the discharge team and let them know that dad needs to STAY right where he is and they need to help you get the Medicaid app started IMMEDIATELY.
Best of luck!!

I find myself wondering what patient these people are treating, because it sure doesn’t sound like it’s your father.

You need to call a Care Conference right now. Call tomorrow before you or anyone else signs ANYTHING regarding discharge to schedule one. Get everyone on the same page. Be respectful but firm. My husband’s rehab wanted to discharge him after a month this summer. Medicare would pay for three months as long as he made progress, which he did. There was a mix-up and miscommunication and all it took was one call to Social Services from me.

Be honest with the PT who thinks Dad is doing so stunningly well. Ask him/her how they can say that if Dad can’t even place his feet right to manage the walker. And, ask why he would even need the walker if you and your mother would have to practically carry him everywhere. I assist my husband with a gait belt, but I don’t pick him up by it which seems to be what they’re suggesting you do. They may have Dad convinced that he’s doing so well when he really isn't. Each therapist keeps notes and there is most likely a head therapist. Ask that they be at the meeting as well. Advocate for him and for your mother.

Barb, what I'm not understanding here is why the SNF would want to send Dad home? Wouldn't it make more sense to tell family he belongs in a SNF, like this one, and our social worker will help you start his Medicaid application today?  Is there something about this that I'm overlooking here?  I mean presumably they want paying customers, right?  Any thoughts on what the facility is trying to accomplish here?

Don't believe the BS that the facility is trying to sell you.

You dad needs to be in a long term care facility. Bringing him home will kill (literally, KILL, your mom).

Go talk to the discharge planning/social work team. Tell them in no uncertain terms that dad needs to remain in the facility and get the Medicaid application started. Yesterday.

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