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I am at wits end. 84 year old mom lives independently (dad died 5 years ago) and started having health issues in Aug. First a fall, 3 days in hospital, then back home. When home health visited, she could not answer door, house was a filthy wreck to the point EMTs left phone # for Hoarder Rescue on the top of the debris field in her kitchen, she had a UTI and was very weak. Back to hospital. Dr recommended acute rehab which she did for several weeks, then she went out to skilled rehab facility. Ended up with VRE in her urine, then C.diff. She is on day 38 of her 100 that Medicare covers at 80% and the rehab is pushing her discharge even though she IS participating in her PT/OT. She is just not progressing.


I've been down to FL twice in the past 6 weeks. I met with PT/OT, social worker and administrator who all state she cannot be on her own. She needs constant cueing, without which she furniture walks and drags her walker behind her like a sad puppy. When in a wheelchair, they have to push her an inch at a time or she freaks out. She is verbally abusive and belligerent (more on that another time - that has always been her go-to personality) and is sundowning, although no diagnosis of dementia has been made. She has COPD (24hr oxygen which she constantly pulls out if her nose,) and heart disease. They state unequivocally she can no longer drive, cook, manage finances or be on her own. I could tell most of this from the state of the house. Neighbors have told me they have had to help her after falls, or she can't move (all the while she cusses them out) and fire dept/emts apparently have been at her house almost on a weekly basis this past year. Mom fibs and says this is not true.


My question is...I am frantically researching ALFs as I know home care would not work. She would run them off in 2 days. The rehab says because she is not making progress she needs to go...but I have nowhere to get her to, since she cannot return to her home. I am taking FMLA leave, unpaid, to go back to FL in a week and start touring places. Meanwhile mom tells them every day her daughter is coming to take her home....while calling to scream and threaten me that I need to get her out of "that place". Can they just kick her out before her 100 days are up? I have paid the facility her $57/copay that started on day 21 so its not financial. I need more time to get her health figured out. Then comes the fight about where she will live.

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Just need to say, that 100 days is not a given and Medicare does not pay 80% for rehab. The first 20 days is 100%, 21 to 100 days 50%. If the supplimetal pay the other 50 % the patient is responsible for the balance.

Tell them for now its an unsafe discharge. That there is no one to care for Mom in her home. And from miles away you cannot set anything up. Could they please give you time to get there and scout out ALs.
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Reply to JoAnn29
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Does she have $?
Like at least 10k available that you can use to pay for her stay? If so, she can move into a place as private pay.
If the rehab she is in as a patient also has a LTC NH unit, and they will take her as a resident, I’d go with having her stay there. She has a nice thick medical chart, they know what she’s like. You’ll drive yourself crazy trying to deal with the myriad of AL, MC & NH options out there plus deal with the hoard pit house.

So do you know what her finances are? If she has no $ to private pay then she will have to file for LTC Medicaid. In this scenario, it’s to have her transition from Medicare paid rehab patient to Medicaid Pending resident. For Medicaid she will need to basically be “at need” both medically and financially. Medically will be determined by what’s existing in her medical chart. If rehab is also a LTC Nh, they can look it over to determine if it meets “at need”. I bet it does. Now for the financials, she basically has to be impoverished with her nonexempt assets at a max of 2k and her monthly income under the max set by FL. If all she gets is SS $ & no other monthly income she’s going to be under the max. That house with the Lady Bird is a nonexempt asset so don’t fret on that. But remember you’ll have to basically be paying the whatevers on the place till forever. But hey now you can get crap thrown out!!!

I’d be very concerned that if you allow her any decision making on all this, she’s going to leave AMA (against medical advice)& land back at that house with have an ever worse fall and fetidness, yet another ER run & hospitalization. You come rushing back down from Illinois. Rinse & repeat. And it will be amid the Winter Covid wave. Pleae if you can don’t let this happen. The simplest is she stays where she is now. Yeah she will be quite quite peeved. But she’s gonna be unhappy no matter what, right?
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Reply to igloo572
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I would ask for a needs assessment to ensure that you are looking for the best facility to meet her care needs.

Remember to look into board and care homes. They tend to be cheaper and have a better ratio of caregivers to residents.

Best of luck finding the best fit.
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Reply to Isthisrealyreal
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If there is no action on your part they would go to court to appoint a guardian for her. I am glad you are taking the time to start looking. It sounds like you will need to determine if she has funds to pay on her own and or you will need to assist the social worker on getting Medicaid started. Find out if the recommendation is for assisted living or nursing home care because most Assisted Living are private pay to the tune of about 7000 each month. It truly sounds like she needs psychiatric hospitalization first followed by nursing home . I doubt an assisted-living would take her in this condition and if they did you will start getting calls within a matter of days saying she needs to be somewhere else. This is going to take a lot of work on your part during your leave of absence. Once completed, you will feel much more at ease
Ignore ignore your mother's Rants and Raves. It is all part from her illness.
Once once she is settled you can tackle the sale of her home. If she fully owns it, you can apply any Professional Services to the bottom line.
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Reply to MACinCT
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Dear "Chicagoannie21,"

I'm glad to read all the things you plan on doing in your situation with your mom. I understand you very well. I am an only child too, her medical and financial P.O.A. and have zero help or input from her family who range in ages from 75-90 and all live in other states. So it's just my husband and I who handle everything as it comes up.

When my mom was in the rehab facility, I couldn't go in either but, she had a room by a window and that's when I first had the ability to see her since February 28th through "window visiting." Being that my mom is 95, most of her friends have already passed away, one is in a care facility and is unable to reach out and one family friend doesn't want to see my mom in her condition - she says she wants to remember her as she was.

Her rehab facility originally was going to keep her for maybe 10 days so that's why I said I was so thankful that she was there long enough to work feverishly in order to find a new facility through the Placement Agent. Everything has been working out very well.

I'm glad you will be requesting her to be tested for dementia even if they could start with just a basic MMSE (Mini Mental State Exam) that would at least provide a clue. It's a 30-point system. She used to score between 23 and 28 over the past several years but, her latest score is down to 14. Even the Neurologist she went to would use that.

Just wondering if she's ever been tested for a UTI as that causes a lot of different reactions i.e. hallucinations, confusion, agitation and many other things as it affects people differently - just a thought.

In her memory care unit at her ALF, they do a care plan using a point system. So she is currently at a Level 3.

Wishing you much luck!
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Reply to NobodyGetsIt
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Thank you everyone for your input. I will call the rehab and ask about a Placement Agent. I will request if they can get her tested for dementia or to see if maybe she had a small stroke, as her ongoing health issues don't seem, to me, to explain the decrease in cognition and her inability to properly use her walker, rollator, etc. Late July she was still driving, doing her own grocery shopping, folding up the rollator and putting it in the trunk of her car, etc., all on her own. While telling anyone who offered assistance to F-off. I will also ask about the respite care option if they call and tell me she needs to be out immediately.

I would feel a lot better about their recommendation for a Level 4 AL with memory care as a future option probably sooner than later IF she actually has a dementia diagnosis. When she calls on the phone, her nastiness is usually quite on point. When I met with the rehab 2 weeks ago, I kind of begged for the therapists to find some area of progress. She is walking 170-225 ft but has to stop and rest every 60 steps or so but she is stubbornly doing all the therapy as she understands if she doesn't, Medicare won't pay. Rehab originally wanted her d/c'd on 10/16 but have given her more time but no exact date.

She is in a really good rehab and I have been very impressed with all staff I have interacted with. Covid makes all this more difficult as I have not been able to physically see her, and am just going by what staff is reporting to me and mom's dreadful phone calls. Everytime I see the rehab # come up on my phone, I have that pit of dread in my stomach. I am the only child, and her medical and financial POA. Zero other family to assist with decision making and mom has no friends due to her abrasive personality.
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Reply to Chicagoannie21
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Thank you everyone for your input. I will call the rehab and ask about a Placement Agent. I will request if they can get her tested for dementia or to see if maybe she had a small stroke, as her ongoing health issues don't seem, to me, to explain the decrease in cognition and her inability to properly use her walker, rollator, etc. Late July she was still driving, doing her own grocery shopping, folding up the rollator and putting it in the trunk of her car, etc., all on her own. While telling anyone who offered assistance to F-off. I will also ask about the respite care option if they call and tell me she needs to be out immediately.

I would feel a lot better about their recommendation for a Level 4 AL with memory care as a future option probably sooner than later IF she actually has a dementia diagnosis. When she calls on the phone, her nastiness is usually quite on point. When I met with the rehab 2 weeks ago, I kind of begged for the therapists to find some area of progress. She is walking 170-225 ft but has to stop and rest every 60 steps or so but she is stubbornly doing all the therapy as she understands if she doesn't, Medicare won't pay. Rehab originally wanted her d/c'd on 10/16 but have given her more time but no exact date.

She is in a really good rehab and I have been very impressed with all staff I have interacted with. Covid makes all this more difficult as I have not been able to physically see her, and am just going by what staff is reporting to me and mom's dreadful phone calls. Everytime I see the rehab # come up on my phone, I have that pit of dread in my stomach. I am the only child, and her medical and financial POA. Zero other family to assist with decision making and mom has no friends due to her abrasive personality.
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Reply to Chicagoannie21
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Rehab currently have the Duty of Care. If rehab is no longer suitable & home is not suitable/safe either, then an inbetween place is needed until the appropriate place is found. By Mom (if capable), but usually by the enduring POA. Sometimes even Guardian is needed to this point.

Where I live any patients at risk of not getting home would be flagged early for social worker to have on their books.

We call our inbetween place either *respite care* or *transitional care*.

Don't panic. Ask to speak with the discharge planner or social worker & find out what they call the inbetween place.

You will have to decide on a facility & whether this is near Mom's house or near yours. You may wish to ask if any free/low cost counselling to support you through this process.

PS a thorough neuro exam by a Geriatrician or Pschologist will be beneficial to find out just what is going on with Mom & to choose the right level of care. The medical team will probably suggest this, if not, you can.
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Reply to Beatty
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This is what is known in the aging process as *the crises*. But don't panic. Just recognise this fact.

Rehab currently have the Duty of Care. If rehab is no longer suitable & home is not suitable/safe either, then an inbetween place is needed until the appropriate place is found. By Mom (if capable), but usually by the enduring POA. Sometimes even Guardianship is needed to this point.

Where I live any patients at risk of not getting home would be flagged early for social worker to have on their books.

We call our inbetween place either *respite care* or *transitional care*.

Ask to speak with the discharge planner or social worker & find out what they call the inbetween place.

You will have to decide on a facility & whether this will be near Mom's house or near yours. You may wish to ask if any free/low cost counselling to support you.

Best wishes to you on this next stage.
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Reply to Beatty
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Before they discharge her from rehab ask to speak to one of the facilities social workers. Explain to them what her house is like and that there is no one to care for her at home. They will likely put her into respite care wherever there's a bed available until you or the state are able to make a permanent situation for her.
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Reply to BurntCaregiver
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Dear "Chicagoannie21,"

When my mom nearly died of severe dehydration and COVID back in April, I had her ALF send her to the ER where she stayed for 4 days and they sent her to rehab. My mom used to be able to walk and dress herself until that point. She is 95 and the Discharge Case Manager kept wanting to know where she would be going upon release. We didn't want to send her back to her ALF because of what they allowed to happen to her without our knowledge. She ended up being on a week-to-week basis with the rehab facility as she was too weak to do the physical therapy. It was by God's grace that they kept her nearly 30 days. The Discharge Manager gave us the name of a Placement Agent that she worked with on the patient's behalf. This was in the midst of COVID so it was very hard to find a facility who would take someone who had COVID. The placement agent was extremely helpful because she had the connections, knew all types of facilities and had good communication with them. She gave us the name of three to choose from. My mom has Alzheimer's and as of May is in a new facility and in the memory care wing as well as under hospice care because she is no longer mobile and has lost a lot of weight.

So my suggestion is to ask the discharge manager of the Skilled Rehab Facility if she can recommend or works with a Placement Agent who can help you in finding the appropriate place for your mom with the health issues she has.

I wish you and your mom the best!
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Reply to NobodyGetsIt
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