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I've been trying to get my dad into a SNF since July. It's just been a lot of red tape and I've had to get guardianship (not cheap). The first SNF we were working with decided they didn't want to take him (after weeks of working with them) and basically blew me off, saying they didn't have a bed. I found another and have been working to get his medical eligibility from the doctor, but the doctor is apparently not sending the SNF what they need and so I've been acting as intermediary, trying to get what the SNF needs from the doctor. It's ridiculous that I need to do all this. The doctor agrees he needs to go, but there's no communication between the SNF and the doctor!

My dad fell twice over the weekend and I took him to the doctor this morning and practically BEGGED him to complete an evaluation form and send it to the SNF (which he agreed to do). The doctor said if he falls again to call an ambulance and have him taken to the ER and then refuse to allow him to be discharged to me - basically I tell them he needs to go to a SNF and there's no one to look after him of he is discharged. He said if they try to guilt me into taking him home, I have to refuse! I've heard this before, but since I have POA and Guardianship, can the hospital force me to take him? I've been practically living in his home for a couple of months while waiting for a bed in a SNF to open up but it can't go on - this isn't my home. My work is suffering as I'm constantly dealing with my dad. I know that this is how most people get into SNFs - 3 days inpatient hospital stay then 20 days Medicare then transition to Medicaid, but can I really refuse to bring him home and insist they keep him and then transition him to a SNF?

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My 87 yrs. old mom is currently in University of Tennessee Medical Center. We are from Indiana. She has dementia and had a stroke two weeks ago. They have refused to give her any kind of therapy. PT or speech. I can't get over to see her as we have 1 car down here as brother is working at Dollywood. They have been DEMANDING we pick her up. I thought I had a facility to work with her so she can swallow. They aren't even trying to feed her. Facility won't take her because they just know she won't improve. Social worker is pushing to get her out of there. I can't take care of a foley catheter, I can't lift her, and I can't get her into our Astro van using two running boards. Just because she has dementia, which was doing just fine, until the stroke, they don't want to help her or us. I've been trying to get through hospital administrator, but they are never around. We're in a pickle, not knowing who to turn to next. Been trying to connect with her Indiana cardiologist to see if he can help get her home again. Here they say she isn't medically necessary to be in hospital. What do you call it if you can't swallow, and they refuse treatment?
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People, falling parents does not necessarily mean a trip to the SNF, remember they need to qualify for placement (skilled need). Baby sitting (custodial care) to prevent falls does not qualify for placement. Family members need to stop thinking that the hospital is the end all for their parent problems. Families need to start taking responsibility and begin talking with their elders ahead of time to prevent a "social dump." This means placing the family's responsibility which should have been addressed way before the multiple falling issues become more frequent on an acute care hospital. There are so many programs and resources that a family can obtain to direct them regarding placement.
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Follow your doctors suggestions, do not be bullied; stand strong; take care of the caregiver.
No, the hospital cannot force him to go home unless there is a qualified 24/7 qualified caregiver. Yes, if he has been in hospital for 3 days, then Medicare will pay for him in
assisted living/other situation. I do not know Medicaid procedures
. If he continues to improve, Medicare will continue to pay. If not, perhaps Medicaid steps in now or he can be cared for at home with a nurse or other qualified caregiver.
However, this can represent a BIG out of pocket. Ask anyone you can think of for suggestions or referrals to a nurse/aide. Also remember that there are people who will care for individuals in their homes.
Always check references on caregivers - some states register some caregivers - check with State Board of Licencing to see if any complaints have been filed against someone you are to employ.

Good luck and remember to take care of the caregiver !
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Medicare has strict requirements and the main one is the 3 day inpatient stay. There are some other req. as well. Payments are only to a SNF. The first 20 days are 100% paid. The remaining 80 days are 80% with 20% co-pay. This is not for custodial care. If the patient does not show improving they will terminate the stay. Go on line and get the "Medicare coverage of skilled nursing facility care" document
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I do not agree with SWM. There are many court appointed guardians that are not required to provide care in the home. It is the job of the guardian to determine whather appropriate care is being provided in any location. If not appropriate then they are required to find the level of care necessary.

Just imagine if guardians were required to provide the care, there would not be nearly as many people working in the profession. If providing care was required since many guardians have many clients how in the world could they manage?

The guardians job is to identify appropriate placement and make it happen in collaboration with hospital social workers and other medical staff.
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Just so you know, since you are the guardian, you can be called is as adult abuse for refusing to take him home or care for him. By arranging to be his guardian, there are now more legal obligations on you (depends state to state as to the legal levels) but you agreed to more obligations when you were given the guardianship. You may want to talk to legal counsel before you refuse to take him home. You could be charged with abandonment or neglect. Sorry for the bad news, but thought you might want to check this out. The other thing no one tells is that not every facility has Medicaid beds so he could end up many miles from you. In addition, Obamacare is slated to dictate what is and is not acceptable starting in January, 2015 so all that has been standard procedure may not be standard procedure as our country adapts to national healthcare standards like other countries. Good luck.
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Not sure where you are located.In MA, most nursing homes no longer discriminate between private paying and medicaid patients; however, they do like to get those 90 days of medicare payments, which they can only seem to get when someone is discharged from a hospital with a medical order for skilled nursing care. ERs are notorious for discharging patients, especially those with dementia, because they cannot just admit them to the hospital, and are overwhelmed by the growing population. I once had to abandon a relative in an ER because I lived out of town, knew it was an accident waiting to happen, and could not care for him. I had been trying to get him services,unsuccessfully, for over three months and knew that he was in real danger. The ER doc called me several times the next day,trying to guilt trip me into taking him home. I just kept telling the doc that I could feel his pain, but could not, in good conscience, discharge him. He spent 3 days in the ER and was then admitted to the hospital. Once I was able to develop a relationship with the hospital social worker and reviewed allI had been through to get him services, she agreed that there was a gap in the system. In this case, the patient had a rare degenerative brain disease that was not well understood, was already on medicaid, but was under 60; therefore agencies like Elder Services had nothing to offer. He ended up spending about 30 days in the hospital while they helped me apply for guardianship in order to place him in a nursing home. Their system involved sending his profile out to their comprehensive list of nursing homes. Once they get three acceptances, the family must choose one. The hospital referred me to their lawyer to apply for guardianship and had prepared me to foot the the 3K fee; but fortunately, the attorney informed me that I was not responsible for this payment and that if the patient did not have means, the hospital would pay for it. I did not feel proud of abandoning my relative in the ER, or of letting the hospital pay for guardianship. However, I shudder to think of how things might have played out had he not been admitted to the hospital, and later the nursing home. I was working for very little money at the time, and trying to finance college tuition for my own children, so although I would have otherwise paid the fee for guardianship,it would have been a hardship. Hospitals are very quick to discharge people without suitable discharge plans, and often intimidate families with medical bills. Just recently,my mother's day care rightfully sent her to the ER because they thought she was having a stroke. They did the usual tests and concluded that the symptoms were caused by the antibiotics she was taking for a sinus infection. They wanted to discharge her immediately and in fact asked that she go right back to day care so that their nurses could keep an eye on her, just in she had had a TIA that didn't show up on the tests. The day care nurses, rightfully, resented the hospital's assumption that they could do this and didn't want her back until the following week. Since she can't stay alone, and the whole episode had disrupted her usual day care schedule, I was able to get her admitted into a SNH where she regularly goes for respite care. This particular discharge process should not have posed a huge problem for the hospital social worker; nevertheless, they would have been very willing to discharge her and let me pick up the pieces had the day care nurses and I not pushed back. The point I'm making here is that, with hospitals,admitting and discharging patients comes down to dollars and cents. Elderly people, especially those with dementia, are vulnerable because they often require nursing home services (medicaid) rather than skilled nursing home services (medicare). But you are not obligated to let them discharge a patient into your care if you can't take care of them, even if you are living in the same home. Nor can they make you financially responsible, even if you have POA or guardianship You must push back.
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Yes, have him taken to the hospital. . You can refuse to take him home
if there is no one to provide adequately for him there.
If it has been necessary for you to get guardianship, his condition sounds as if warranted it.
Social workers are of great help in finding a bed - this is their job.
Please explain clearly to your Father what is going on and that you love him
Stand your ground!.
Take care of yourself and of your husband.
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Please be sure to talk to your dad about what you're planning. Don't just put him somewhere without his being able to know what's happening and why. We will all (hopefully) be old someday, and wouldn't want to be handled like a house pet that needs ridding. I understand fully when you need round-the-clock care with an elderly parent....my dad was hospitalized after living with us for 7 years with pneumonia, sepsis, and once there, he needed breathing assistance and tube-feeding. Only skilled nursing could handle him in that condition. But love your dad and be very reassuring to him every step of the way. You're under stress, but please think of the stress he's under as well.
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Louise, ditto what Veronica just said, but another big thank you for telling us all in such detail how you did it. Maybe you should write an article for AC!
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Louise I can not praise you loud and long enough for the care you took placing your LO. It was a monumental task for you to accomplish and you did it so thoroughly and with such good grace. I hope your loved one is truly grateful for all the time and effort you put into making the right selection. The detail you have written will help many people faced with the same difficult situation. You are truly a wonderful wife.
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Pyrrhe, not sure where you are at in Alabama, but I worked with a Sava Senior care facility in Houston, TX to place LO in a medicaid pending, I see that they do have some facilities in Alabama- I was in the same situation not able to pay the 4,000 to 6,000 for private pay so I was limited to a facility that would take Medicaid Pending. It is my understanding that the states requires some of the facilities to have both Medicaid Pending and Medicaid beds available but it is a limited number.

My LO was falling two to five times a week at home, not able to walk or get himself up and down and was totally incontinent, plus weighs 300 lb and I'm am only a third of that, I was his only caregiver and had to leave him alone while I worked which was just not good. I wanted him in a facility for his safety. My situation was such that my health was declining taking care of him by myself while trying to work and take care of all of my chores as well, it was just too much for me and could not afford full time help to care for him. I took him to the ER a number of times after his falls, they always just checked him out and sent him home, so waiting until he fell and broke something was not an option for me. I never tried to refuse to take him back so I really don't know how that would have worked.

I was desperate to get him into a facility and was trying to check places out in the evening or at lunch, was not getting a lot accomplished. So I just went to my boss explained what I needed to do and took two days off of work. Like you, I had been missing a lot of work with him and hated to take more and I was lucky my boss was very understanding and even gave me a few tips. I did some internet research and the Department of Aging here in Tx has a listing of all nursing homes that accepts Medicaid, I called as many as I could to find out if they took Medicaid pending and made a list of the ones I felt were okay. Note, I did not do this on my days off but rather in the evening and lunch otherwise I would have probably had to have taken another day. I made a map and my first day off, I went and visited as many Medicaid accepting facilities that I could including a few that I knew did not have Medicaid Pending available, as they can put you on a waiting list. I visited 8 nursing homes that day and talked to the administrative staff at each one - explaining my story to them, they were most helpful and answered a lot of questions for me, one of the facilities that did not have a Medicaid pending bed actually made some calls for me and recommended a sister facility (this was a Sava Senior) that I eventually placed him in - one that was not on my list so it was a huge help.
But ask a lot of questions - one of the places that was close and I really liked would have crammed him into a room with 3 other people - that was something I noticed in the walk thru that they had some 4 people rooms and I had to ask to clarify that - and indeed the 4 people rooms were Medicaid pending, I did not feel that the transition from home to NH for a dementia patient would be very smooth even sharing a room but 4 in a room (a small room) was just too chaotic. So ask a lot of questions.

By the end of that very long day, I was exhausted but had chosen two that had Medicaid pending beds available, a first choice and then a second for backup and knew what they needed to start the process.

My second day, I collected the paperwork that the nursing homes needed as well as bank statements - SS info etc. (In retrospect - I should have done this the first day, as I could have just given the nursing homes the paperwork when I visited as this could have made things quicker. but as I was going back with LO to have him look at facility as well, I just took them the paperwork that day.

I needed full medical record from Primary Care Dr - along with medical record from his Neurologist (this is very helpful in getting him accepted at the NH especially if he has dementia) and record from his last ER visit. I called the Drs offices and hospital in the morning and explained to them what I needed and that I would come that afternoon to pick them up - did not take no for an answer as one of the dr's offices tried to put me off. I had printed out his bank statements for the last six months, downloaded a Medicaid application and filled it out, made copy of his DL and SS card as well as his insurance information and made a copy of his small life insurance policy, I then carried all of this to Kinko's and had 4 copies made, one for each nursing home, one to use with the Medicaid application and a spare just in case.

When I took LO to NH to visit - we only went to the first one because he was okay with that one, I was able to hand them all the paperwork needed to start the process, and a week later I was able to get him into the facility. Now this was not an easy decision and I am still wrestling with guilt - he is being pretty good but asks to come home - but he is getting physical therapy, regular bathing, his medications and has only fallen once in over two months. I know that a lot of caregivers that comment here do not like NH - and truth be told, neither do I, but I do think every situation is different, in my case - since his children would offer no help or support and with his financial situation the SNH really was the best choice for his much needed full time care and safety. I do feel better about placing him because I did the multiple visits - you would expect the more expensive homes to be the nicest, but that was not always the case and a couple of the places I got no further than the front door and I knew that it was not going to work, however, I did the tour and talked with them, well just because I was there and wanted as much information as possible in making the decision.

Now just so you know, once he is Medicaid approved - you can easily move him to another facility as Medicaid approved beds are more available than Medicaid pending.
I may move LO as the facility he is at is not as close as I would like but will leave that up to him, he is about a 25 minute drive, there is a facility about 10 minutes away so I could visit more, but he is adapting and doing pretty well so will think long and hard before moving him.

For your information, the nursing home submitted the Medicaid application on the day of his arrival - approx 8/15/14 and I just last week got the approval back, I do think that filling the form out correctly and providing them with all paperwork required at the time of submission makes it go faster.

Good luck with your Dad, I hope that this helps. I really think that waiting for a LO to fall and seriously hurt themselves before getting the proper help is a very serious flaw in the medical and insurance care of elders.
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The discharge planner at the hospital can assist you in getting him into a nursing home. If he doesn't have assets to pay for nursing home care you can apply for long term care Medicaid. Your local department of human services or social service can assist you with this. You can also contact the Area Agency on Aging or Bureau of Senior Services, they can give you information on options and assist you with the long term care system.
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Hospital staff will do everything they can think of to make you take someone back home. It costs them money to keep a patient in the hospital without funds to pay. They will very rapidly find him a bed in a N/H It may not be the facility of your choice and if Medicaid is the payer you will not be able to move him.
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I'm so sorry your dad is having these health issues, but it is so good you have been able.to do such a great job thus far. I can appreciate yor frustration. The red tape can be daunting. I will keep you in my prayers throughout the day.
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Ours happened just the opposite, the hospital told us that she needed to go to a SNF. You need to speak to a hospital social worker and get the help you need with paperwork to get him in, for us that was really easy it was finding a SNF with a bed available that was impossible.

Once he gets into the SNF please make sure that you check on him every day and maybe even have a camera installed in his room. My mother was only in the SNF for two weeks and she had a mysterious fall.....story has changed 4 times....she hit her head front and back and they only held ice on it, they did not take her to the hospital for 16+ hours and she died 9 days later of "Blunt force trauma to the head and brain hemorrhages." We are just sick as she was able to walk well and take care of her personal needs when she went in. I have since found out that there is an epidemic of "falls" that happen in these homes and the patient dies. No one is held responsible nor is there an inquiry as to what happened....not by the hospital or the police or anyone it seems. They are old and everyone assumes..."well it was for the best" but if beg to differ if there is abuse or neglect. Just watch him...closely!
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There is a "dance" that has to be done, following procedures at the hospital. The staff must try to get you to take him home, and your part of the "dance" is to say that 1) you are unable to provide adequate care for him at home 2) his doctor believes he needs nursing care at this point and probably beyond 3) and to request firmly (just short of demanding) that the social worker find him a placement.

Hospital transfers to nursing care take priority and are easier to do. The nursing facility will love getting all the hospital paperwork transferred with him, including doctor's orders. His primary care doctor probably does not have a social worker, or staff to ensure the initial "doctor's orders" that the nursing home needs.

I would recommend that you have a doctor outside the nursing home to provide ongoing care, you can drive your dad there and sit in. I think the nursing home doctor might be more aligned with the home than with your dad.
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Thanks Debralee. See, this is precisely what worries me. The doctor confirmed I have guardianship and then made his recommendation regarding the next time he falls. The attorney who handled (is handling) the guardianship is actually the wife of the family doctor! I currently have temp guardianship - the hearing to finalize it is next week.
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Having guardianship of individual comes with a lot more responsibility than just having POA. I would not recommend refusing to take your father home from the hospital until you check with a lawyer or the court that granted you guardianship of your father.
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Oh my goodness Tina! This is what I'm afraid of too, especially since I have guardianship. I'm assuming they can't actually have someone arrested for not giving up their own life to look after an elderly parent, but it sure does seem like some will try anything! Hopefully someone else will chime in with more knowledge.
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I tried refusing to take my mom home from er after she called squad while u was at work because she couldn't breathe (panic attack) she had the onset if deminsia and was becoming physically unable to care for herself. She was beyond my capabilities. The er told me if I refused they would have me arrested for elderly abuse and abandonment. It took me months to get her into a facility. It almost cost me my job and my marriage because of the stress I was becoming unbearable to be around. Why would the er lie to me like that?
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It is much easier to get a SNF bed after a hospitalization than directly from home. When he falls the next time, because there will be a next time, unfortunately, call 911 for an ambulance & let the hospital admit him. The doctors taking care of him in the hospital *should* be able to see that he cannot be sent home to live by himself---and you must not give any indication that you are able to live with him & take care of him, you must stress that he lives by himself--they'll have to order that he go to a SNF. It may not be the one you want him to go to, because they do it according to available beds at the SNF's (although some places ask the family if they have any preferences, and they'll try those places first). A hospital cannot kick him out if there is nowhere to go & no one to take care of him since he is unable to live by himself. At the hospital, usually a social worker takes care of getting the evaluations, orders & other things to get a SNF bed. You only have to provide financial information after Medicare stops paying. And don't let the SNF try to dump him on you after Medicare stops paying----they're famous for that. They get their Medicare money & then don't want to keep the patient because they don't want to deal with Medicaid. It is obvious your father cannot live by himself.

Have you thought of trying to get a home health aide for him? If the doctor orders it, Medicare should pay for it. I don't know much about that. I doubt he'd get 24 hour care, though.
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Louise, I'm in AL. It's Medicaid Pending. The SNF I'm currently working with said we'll need to pay his share each month (works out to about $55/day). This is based on his gross income divided by the number of days in the month.
It's ~$6000/month for private pay and I don't have that kind of money and neither does he so there's no way we can go the private pay route.
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Agreed Igloo - the first NH i was working with actually said he might not meet medical eligibility for Medicaid so I looked it up and figured he did and they came back and said, yes he does actually meet medical eligibility, but now we don't have a bed. In actual fact, their concern was his smoking (which they had said was ok) and the fact that he can get agitated. Basically, they didn't want him. But I had done exactly what you said - fixated on the financial without realizing he needed to meet medical eligibility! And the medical eligibility is really strict. It's not enough that you can't make your own meals or remember to eat. No, you have to need assistance actually getting the food to your mouth! (This is in the state of AL).
Anyway, he does actual meet medical eligibility and that's what the new SNF is trying to get from his family doctor. I just don't see why it's taking so long!
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Pyrrhe, what state are you in? Are you wanting SNF to accept him as a medicaid pending patient or are you planning to pay for private care for three months?
I recently placed LO in SNF in Texas without having to break the bank and I refused to wait until he fell and did serious damage to himself, so perhaps I can give you some advice, but it would be specific to Medicaid Pending.
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A friend of mine was in the ER a few weeks ago, kept for overnight observation, he did not have insurance. The hospital prepared the Medicaid application on the spot and it was approved the first of August, before the hospital admit. So, if there is a medical reason it is possible to have Medicaid in place retroactivly.
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Geo - I think the stumbling block is that in order to get into a NH you have to have medical orders of some sort. We can get them out of their home, find the NH and do the paperwork for admission BUT they have to have MD orders to get in. For those coming to the NH from being in a hospital, they usually are discharged to a SNF/NH for "rehab" from their hospitalization (hospital stay paid by Medicare). Usually this seems to be a from a fall & the broken hip, knee, whatever. I'd imagine that the vast majority get into a NH through this route. Then once in the NH, they aren't able to do the rehab (which is paid by Medicare) so after the 21 day "rehab" benefit, they end up staying in NH and either family applies for Medicaid or does the spend-down by private pay or has LTC that will pay for a while.

Now there are very expensive all private pay medically supervised facilities, that will take residents without a skilled nursing orders done. Maybe the sort of place that the very wealthy, like a Sunny Von Bulow, ended up in that cost 20 - 40K a month. If family has the $$$, they can get their family member moved in.

But for the rest of us, the NH needs medical orders done. Pyrr's dad has no real $ anymore, he will need to apply for Medicaid to pay for his NH stay. Medicaid has 2 tracks to qualifying them to pay for care. A financial track - which family has to do to show that the elder is now impoverished with about 2K in non exempt assets & 2 K in monthly income and a 5 year lookback. And ALSO there is a medical track - for my mom the state sent a RN team to the NH to review mom's chart to make sure NH was medically necessary (my mom moved to NH from IL no hospital stay, no AL). Mom actually had a glitch in her chart - this even though her MD was the medical director of the NH!! There is always something!. The intake staff did not transfer all mom's medications to her new NH chart, they just noted the Rx she brought with her. Now that one was a pretty simple fix. But mom - who has Lewy Body Dementia - seemed back then pretty cognitive & competent. So she needed to have something in her chart for a "co-mobidity", so they added .81 of aspirin for CHD and changed the delivery of her Exelon, so she was good for skilled nursing needed.

Most of us fixate on the financial for Medicaid as that is what we have to deal with, but the medically necessary is just as important if your state sends out a medical evaluation team, they can find them not medically necessary, so Medicaid will not pay.
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Two things we learned with my mom....make sure they have a diagnosis on record, that he is admitted in-patient and not under observation. We tried to refuse discharge when she'd been classified as under observation and were unable to challenge the discharge plus it affects what medicare pays.
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Here's a question for all:
Since she has POA and Guardianship, can she sell his house, thus forcing him to move somewhere else?

I don't know if this is a good idea, necessarily, but once my mother's house was sold, she stopped thinking about moving back home, alone, and she really could no longer live alone, so it was only an option in her own mind.

I'm just throwing this out there...
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Pyrr- I got my mom into SNF NH from IL. Bypassed AL completely. Was able to do this by having the medical director of the NH she was going into become her doc. The group he was in at the time were all geriatricians who were medical directors of several NH. They know how to do the medcal file that will work to establish skilled needed. If his current doc just won't get you the paperwork, perhaps look into doing it this way.

For mom, it was about 6 mos of every 4 -6 weeks of appointments, and the one she had a 10%+ weight loss & bad h&h Doc wrote the orders for skilled nursing needed. It sounds like your dad already presents with enough critical issues, that skilled required orders can be written on the first doctors visit.

All of this is so emotionally difficult and the paperwork maddening.
Sometimes I can understand why family has a Blanche Hudson moment.
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