My father (78) is a past stroke victim who ended up being mostly paralyzed on his right side. That was 16 years ago, but he had rehab and was able to regain some movement in his leg, was able to do minimum walking. Fast forward to beginning of October, he started have trouble walking and even standing up and bearing his weight. We ended up taking him to the emergency department where we discovered he has a DVT in his stroke affected leg, which I guess explains the weakness hes been having in that leg. The ED ended up having him transferred to an acute rehabilitation center, but his stay cannot exceed 21 days there. They are looking to discharge him on 11/05 although he has made very little progress. His PTA says he is standing better than he was when he initially was admitted but there is still a lot more work as he is not bearing a lot of weight on his leg & he is still not walking. His PTA also stated that he is an excellent patient and always willing to try whatever is asked of him, he’s very motivated. The issue we’re having here is…. we have a discharge meeting today and my mom spoke to the case worker last week on the phone and their plan is to discharge my father to home, with home health coming in at some point. My mom is the sole caregiver for my dad and does not feel like he is ready to return back home. She is afraid that he has not regained enough of his strength back to adequately take care of him at the house. What can we do/say to the case worker today in the meeting to explain or advocate that we feel like my dad would benefit for more therapy? When he was first admitted we were told there was an option for a transfer to another facility if needed, since the one he is at now is only short term. But we’re a little concerned now since the case worker last week said on the phone he’d be discharged to go back home.
Please give any advice on how we can best advocate for my dad’s care
"1. Understand “Medical Necessity” and “Progress”
Medicare requires that you:
- Still need skilled nursing or therapy on a daily basis, and
- Have potential for improvement or to maintain function, and
- Cannot be safely treated at a lower level of care.
If you are still making some progress but the facility says you’re not progressing “enough,” that does not automatically disqualify you from coverage. The standard is reasonable and necessary care, not guaranteed recovery.
2. Request a “Fast Appeal” Immediately
If you’re told Medicare will stop paying:
- Do not sign discharge papers yet.
- Ask for a “Notice of Medicare Non-Coverage” (NOMNC).
- You can file a fast appeal through your local Beneficiary and Family Centered - Care Quality Improvement Organization (BFCC-QIO) (Their phone number will be listed on the notice.)
You must request the appeal by noon the next day after receiving the notice.
During the appeal, Medicare continues to cover your stay until the QIO makes a decision (usually within 2 days).
This appeal process is your strongest immediate recourse.
3. Alternative Options if You Must Discharge
If you ultimately must leave the acute rehab level:
- Transition to a Skilled Nursing Facility (SNF)
- You can sometimes transfer directly to a less intensive SNF under continued Medicare Part A coverage if you still need daily therapy.
- Home Health Care
If you’re homebound and still need therapy, Medicare may cover home health PT/OT/nursing visits.
Outpatient Therapy
Medicare Part B may cover ongoing PT/OT on an outpatient basis if you can safely travel.
Private Pay or Supplemental Coverage
If you have Medigap or secondary insurance, it might help with coinsurance or extended coverage.
Medicaid or State Programs
If funds are limited, ask the facility’s case manager about Medicaid eligibility or waiver programs for long-term rehab or in-home assistance.
4. Ask Your Case Manager or Social Worker to Help
Request a care-plan meeting immediately with:
The facility’s case manager/discharge planner
Your therapist(s)
A family representative or advocate
Ask them to:
- Document your ongoing safety risks if discharged now.
- Clarify whether you still meet criteria for extended Medicare coverage.
- Help coordinate any needed appeal, transfer, or in-home services."
I hope this helps!
You can tell the doctor/case worker that it is unsafe for him to be discharged to his home, because your mother can not manage his cares needs.
If the rehab won't keep him longer, you can try a skilled nursing facility which also offers some physical therapy, but it will not be as much as he needs.
You could try and get a Physical Therapist to come to the home and give exercises.
This sounds like such a sad situation. He is not ready to be home, but can not stay in rehab. He will have to be extra-motivated to work on becoming more independent, otherwise, he will become a burden to your mother. She can not handle this on her own. Not for long, anyway.
If he does not improve, and your mother can not manage his care alone, he will have to be admitted to a skilled nursing facility. They will not do enough to support his independence.
Expect a very high level of battling for this if he has Medicare Advantage.
We encountered the same situation with a neighbor who has Medicare Advantage through her teachers union retirement insurance.
Press through his doctors and at the meeting that no one is in the home to provide care.