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At the end of June my dad, who has Alzheimer disease, was hospitalized with pneumonia and dehydration. After the hospital he was sent to an acute rehab facility. While there he acquired C-diff. Also, he is not eating for at least the past month. The C-diff was cleared and now he is ill again and extremely weak. He cannot get Medicaid. Is it time for Hospice?

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Oh another thought on the 100 days. Medicare usually does not run coverage for the full 100 days. They will pay 100% for 21 days post hospitalization rehab, then maybe 100% for week # 4; but after that dad will be required to do a co-pay for this stay. If he is not progressing in his abilities, Medicare will stop paying. There have been some recent changes in just how "progress" is determined. But most of the changes are geared for those with long-term situations like those with Parkinsons, MS, 2ndary polio. Not the aged dementias. Speak with the facility as to how his charges are being billed and what is the anticipated co-pay cost. NH run 5K - 15K a month, but the specialized rehab centers could be much more $$.
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I'd suggest clearly speaking with the facility he is in now if he can transition to staying there. If it is an acute rehab facility, they may not be set up for long term stay like a NH would. Some places are more NH with a rehab section but others are more purely rehab. So ask about that first. That answer may lead you to deciding what next (move back home or to NH). The social worker can set up a care plan meeting at the facility to discuss what options may be for you and your family. I've found the social workers to be a great resource and very neutral in their perspective. Most states require facilities to have them, so their position is secure and outside of the DON (director of nursing who is the supreme goddess of the NH and rules) whims.

About hospice, since it is a Medicare benefit, it is self-directed. That means that the Medicare recipient can select the hospice group. If you are his MPOA, then you can do this. I agree with the others that he may be best off with hospice at this point in time - he will qualify. But back to the "self-directed" details, you can shop around for the hospice group. There are many big national ones - VITAS & Compassus - and then local smaller ones that seem to do more in home hospice services. My mom is with Southern Hospice group which is in several states (she's in TX); they are her second hospice group. I basically removed the first group within the 2nd month as they just flat would not communicate in a timely manner with me. My point is that if the hospice provider doesn't seem to be a good fit, you can change the provider. Simple easy paperwork too.

For my mom, being on hospice is something the NH really loves as it provides so much more staffing for care. She has gotten so much more detailed attention since on hospice. Initially it was RN once a week, aides 3X a week, social worker & chaplin once a month plus specialized equipment. Now it is RN twice a week and aides 5X a week, weekly social worker and chaplin as she is very end of life. My mom's NH works well with hospice, there are like 8 different ones with patients there and the NH provides for a hospice desk at the nurses station for them.

Some NH who might not be all so excited about dad as a regular resident will be more welcoming if he is also coming in on hospice.

For the smaller hospice groups, the equipment and stronger pain meds can be an issue. They may not have the funds or credit lines to get the special beds, geri chairs, geri bath chair, breathing mattress, O2 units, etc. delivered within 24 hours.

If it looks like dad will be needing serious pain management, being on at home hospice can be an issue. For serious pain meds, the smaller hospice companies may not have enough RN's who routinely carry them (the aides don't) so you have to wait till the 1 RN who can do schedule 1 or 2 drugs to get to the dad's bedside. Or the MD /medical director with the smaller hospice are not that 24/7, (they have their own private practice and do the hospice on the side) so you have to wait to get orders changed or drugs added. For NH hospice pain management won't be an issue as they will have the serious drugs on premises or get regular formulary delivery if dad needs something unique.

Has anyone spoken with you about C Diff reoccurring? For men,it seems to be a revolving door of NH, C Diff, then back to hospital, then discharge back to NH. The upside of this is that each time he goes to the hospital - it he is there for the usual week to clear & stabilized - it usually starts a new clock on being on post-hospitalization rehab which is covered by Medicare.

None of this is easy or simple. Good luck and try to keep a sense of humor going amidst all this.
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If he cannot get Medicaid because he has too many financial resources, now is the time to use those funds to pay for whatever care he now needs.

Hospice is a wonderful program, if he is ready for it. If not, it sounds like he needs a skilled nursing home. Where was he living before being hospitalized?

I am so sorry that your family is dealing with the difficult situation.
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VA would be a great option if Dad was a vet. Every vet is entitled to some type of long-term care (LTC) coverage, there are several categories of eligibility which range from co-pay to full coverage. Perhaps start here: http://www.va.gov/GERIATRICS/Guide/LongTermCare/index.asp

If he's not a vet, try the New York City Chapter of the Alzheimer's Association (http://www.alznyc.org). There are social workers on hand to help you figure out next steps. Their number is 1-800-272-3900.


Other resources:

National Association of Area Agencies on Aging - www.n4a.gov
Eldercare Locator - www.eldercare.gov/eldercare.NET/Public/index.aspx

These may crisscross and route you back and forth and round again but mercifully you'll find the right person to give you clear direction.
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Not eating is a very serious indicator, but patients don't last a month unless there is a G tube or IV feeding. I would certainly ask about Hospice, but the decision belongs to the patient.
If he was a wartime vet, you could call the VA.
If he can't get Medicaid, then he pays from his assets until they are spent down. If he gave away assets, you get them back.
Since you are in NY, even life estates can be attached by MERP since 2011.
Many parents gift away money and houses with the unwritten understanding that their kids will take care of them right to the end. The kids unwittingly agree to do this, because they think they can do all the care. More often than not they can't, nor can they pay back.
Hospice will not cover the cost of the Nursing Home. So at the end of Sept you bring him home on Hospice, because you have no other options.
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Ask the doctor if it's time to consider Hospice. If he says yes, then you have your answer. The Medicare benefit does not pay for room and board; thus that 100-day limitation is going to mean your dad will have to be moved or begin private pay. Hospice care is completely paid for by Medicare in the home.

Here's more information: http://www.medicareadvocacy.org/News/Archives/Hospice_HospiceInNursingHomes.htm
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