My mother is 90 and still lives in her home, with my unemployed adult brother living with her. Without going into too many details, I'll just say that for financial reasons my brother has been trying to keep her at home for as long as possible. She's had a few stints in a rehab after being hospitalized for illnesses (pneumonia) and they've been nice places, with good food and activities and even visiting entertainers. Each time I've gently suggested that she might be able to stay there one day, but she would start crying and getting upset, saying she has her own home and doesn't EVER want to go in a NH. I think she remembers the awful places my grandmother and great-grandmother were in the 1960s and 70s. She is a very stubborn woman and I've been dreading this NH issue for many years. It certainly hasn't helped having my brother side with her - it's been two against one. I am her DPOA, but do not have a medical POA; stupid, I know.

It's been a rough road the past few years and both my mother and brother, for their own personal reasons, have fought her going in a NH. It's now becoming apparent that we're nearing the end of the road for her staying at home and she will need to go in a NH soon. She is on a cocktail of meds that are keeping her fairly healthy for her age, but she has mild to middling dementia and worsening arthritis in her knees. There was an awful flareup of pain last week and an ambulance took her to the ER. They were unable to do much else but give her a painkiller injection and a lidocaine shot, along with a cortisone shot which didn't work. We didn't think she'd be able to get around the house too well when she got home (get on and off the toilet, etc) so we pretty much begged her doc to admit her, which he refused to do for an arthritic knee. We brought her home (with difficulty, after that painkiller), and she's been in pain but stable ever since. We have an appt with an orthopedic this week.

The helplessness we felt that night in the ER when told they us they wouldn't admit her was just awful. It was really obvious my brother wouldn't be able to handle taking care of her and I work and have my own family to care for. I asked to speak to a social worker about moving her to a NH that very night but was told since it was a Sunday night, there weren't any available. I think that night, coupled with my mother's increasing hygiene problems and dementia, has shown my brother that our mother can no longer live at home. I spoke to an elder lawyer a while back and the house will probably be transferred to my brother, as a "caretaker child". From that moment on, he'll own the house and be responsible for all the bills, which is the reason he's been fighting putting my mother in a NH for so long. Hiring an in-home caretaker is out of the question due to the cluttered condition of the home and other problems which I won't go into. We now have a home health aide coming in twice a week to bathe my mother and, while I'm thrilled that she's finally getting clean, it's been causing it's own kind of problems having someone come into the house.

I always thought my mother would move into a NH after another stint in the hospital and then rehab. I had hoped that it would be a natural progression. But it's obvious to me now that she'll probably need to go in one not due to illness but because of my and my brother's inability to care for her ourselves. My question to the message board is: how do I get her into a NH directly from her home? I can't imagine just loading her up into my car and driving her there; she would most likely throw herself out of the car. Is there a procedure? (I've already picked the NH). Also, does anyone have any advice on what we should do if (more like when) we're back in the ER with our mother and they won't admit her and there's no way she should be going home that night because we can't care for her? We're in NJ, by the way.

Thank you in advance for any advice or stories about your own experiences when moving a parent to NH directly from their home and how you got through it. I really appreciate your support.

Thank you,


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Deedee this will be long.......NH (aka skilled nursing facility/SNF or long term care/LTC) is paid for 3 ways: 1) private pay by elder or their family; 2) from LTC insurance; or 3) by qualifying for MedicAID. Medicaid and not MediCARE.

MedicAID rules determined by each state & are state specific even though it is a federal & state program. Medicaid is needs-based. You are expected to spend your assets first and foremost before the state will pay. There are things you can do to reduce assets but these need to be done by someone qualified to do this that will pass your state's review. An certified elder law attorney is best.

For NH Medicaid eligibility, an individual must show that:
1) are 65+ (can be younger if qualified disability),
2) medical condition requires skilled level of nursing care,
3) monthly income at or below their states max (about 2K),
This is the “income test”– how much $ do you make. TX is $2,094.
4) all countable assets are at or below 2K
This is the “asset test” – how much $ do you own.
5) not gifted away anything of value during 5yr look-back period.

If you do, could be a “transfer penalty” when items are gifted. Penalty different for each state as it’s based on each state’s daily NH reimbursement rate. For Texas, it is $ 142.92 a day rate (2011).

Max look-back is 5 yrs. Most states require 3 – 6 mo. of financials with initial Medicaid application. Can require more financials if something pique’s interest. Financials are bank statements, social security and retirement statements, insurance policies, etc.

INCOME: If it is that every month they are over the states income limit BUT not enough to pay in full for the NH and qualifies for NH in every other way, then they can see an elder care attorney to do a "Miller Trust" or a "Qualified Income Trust". Say mom gets 1K from SS & 1,500K from retirement every mo. Income=$2,500. Basically $ 500 over ceiling for monthly income. No matter what is always is $500 over. So this excess $ 500 is what funds the trust and therefore mom’s income is now 2K and within the states income ceiling. The beneficiary of the trust is state's Medicaid program and upon death reverts to the state. Miller really has to be done by an attorney who does elder law as it needs to be flexible/adaptable and meet the criteria of each state's law on probate (death laws) & Medicaid rules.

ASSETS: All assets are counted, unless the assets fall within the short list of "noncountable" assets:
- personal possessions,
- a vehicle (some states have a limit on the value)
- their principal residence, provided it is in the same state in which the individual is applying & the house may be kept with no equity limit if the "community spouse" lives there; otherwise equity limit is 500K (750K in some). House does NOT need to be sold, is a "non countable" asset but elder will have no $ to pay for anything for house as all $ less a small personal allowance has to go to NH each mo.
- prepaid funeral(irrevocable, NCV, usually 10K max)
- small amount of life insurance (usually $1,500 & NCV)
All other assets (savings, stocks, whole life, rental property) are counted.Must “spend down” to get to their states max to qualify.

The financials are what most folks focus on. But remember that they also need to medically qualify for the need for skilled care for Medicaid.
Helpful Answer (8)

what is medically qualified list for skilled nursing facility?
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After my mother shattered her hip in her home (she lived by herself), she ended up in a rehab and the plan was for her to go back home again. (I knew how adamant she was about never going into a nursing home. She used to say "shoot me first"). Her rehab stay turned into living in a nursing home for the last 2 1/2 years of her life. Even though I worked full time, had young kids, and was married I saw her every day. I'm an only child so it was all on me, and there were many days when I'd leave the nursing home, I'd cry on my drive home. Mom is gone now. I'm sooo sorry that she ended up in a nursing home, but those were the cards that we were both dealt.
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I'm sorry it took me so long to answer. I thank everyone who responded to my question. My mother took an even worse turn on Tuesday and we had to hasten her admission to a nursing home - thank God we were able to get her into the one of our choice that very night. I transported her from the ER to the NH myself, where the nurse on duty picked her up out of my car and put her in a wheelchair. My worries about her screaming and crying about leaving her house were all for nothing - she totally accepted going to the NH as she knew she really couldn't get around anymore without help. The arthritis in her knees is so severe, there's no way she can walk now. All I can say is I loved her more that night than ever before because of how understanding she was about going into the home. I always thought I would have a helluva fight on my hands but, in the end, she knew it was the best thing. She's very happy every time I see her now and she's making friends and playing bingo. Someday I'll tell this board the tale of the extremely uncooperative doctors, ER and hospital social workers, who all did absolutely nothing to help me that desperate day my brother and I knew we would be unable to bring her home from the ER. It was like being in hell that day, but it's over now. Now I face the financial and legal problems of dealing with my brother, who has lived in the home his entire life and been unemployed for almost ten years. We have an appointment with a lawyer next week and, after researching elderlaw and Medicaid apps for the past 5 years, I think I know what lies ahead. He has the option of taking over the house as a "caretaker child", but he does not have an income to pay the bills. I think he's hoping to get some kind of lump sum for being her caretaker these last few years, but I know doing that will put our Medicaid app in severe danger. Well, at least my mother is finally in a good, safe place.
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Tweet - 2 years? So I'm guessing mom about $125,000 to $200,000 in assets. You are fortunate that this $ enables you to do things for her - like new top of the line hearing aids, wheelchair or walker, expensive dental care, several pairs of new glasses, new durable and easy on&off clothing, cable, etc and other items that Medicaid will not ever pay for and you can buy for her. Also you can buy and pay in full for all her funeral and burial expenses with her $. She can pick & choose which NH to be in & pay for extra caregivers. You are not loosing $ per se but spending mom's money on mom's needs & mom's care when she needs it most

This site has articles on Medicaid Medicare and how they are different. Also if you go back on this post to the beginning there are posts from myself & others with our experience in going thru the NH & Medicaid.

What you need to realize is MedicAID is a needs based program. So in order for your parent or anyone to participate and benefit from MedicAID you must be at-need. "At Need" basically mean they have +/- $2K each in assets and monthly income in order to qualify. But can have a home and a car (which are exempt assets). At-Need basically means they are poor and at poverty level. All their assets and income for 5 years prior to admission to a NH must have been used for them or their care (like private duty nurses or home health care agency) or their wholly owned property (like their home). If everybody could go and empty out our parents bank accounts and transfer all their property for zero to others today, and then apply for Medicaid tomorrow, the system could not pay for it and there would be no Medicaid program for anyone to be able to use.

If any assets or monthly income are transferred to you or others, then the state can impose a transfer penalty against the elder via their representative (this would be you as her DPOA) for the amount of funds based on the state's NH Medicaid reimbursement rate. The transfer penalty is a total cluster to deal with as it usually happens after the elder has been in the NH - perhaps for a few months - and then the state in it's require due diligence has found that mom transferred a car worth 20K and cashed in a 10K Treasury bill before she went into the NH. 30K transfer penalty. What will happen is that the state will send whomever is the residents family contact and the NH a letter that the elder is out of compliance with Medicaid and the $ amount and length of time. NH will require you come up with the $ and sign off a promissory note &/or hefty deposit or you get the dreaded 30 day notice (that they have to move and believe me no other NH will take them except by private pay contract with a deposit upfront). This is a total panic situation to be in and a terrible situation to place you parents in.

So in Texas, whose transfer penalty is about $ 145 a day, a 30K transfer would mean someone would have to private pay for 210 NH days. Each state's transfer rate is different. TX is a a low Medicaid reinbursment rate state.

Remember if and when you apply for Medicaid, you, as DPOA, basically sign off on an all-access pass to all your parents financial and legal. You have to provide for 3 - 12 months of their financial and asset and income information with Medicaid application. Which the NH usually vetts before they will even accept a resident as "Medicaid Pending". Many NH which have multiple homes have a regional admissions person who reviews whatever you provide before it even gets sent by the NH to the state program along with the NH's bill.

Property records are recorded by the local assessor and then folded into the state's data base, so moving property ownership will come out. Interest paid on savings or investments are available via IRS or state, etc. All their info is just keystrokes away and eventually it will be found out. If your state uses HMS for compliance, they will be able to find out to the penny every cent spent as HMS has a extremely good system via algorithms for compliance and recognizing patterns of fraud. HMS does compliance for Medicare (via CMS) & federal insurers.

For my mom, she was in IL before the NH, so her 6 months of bank statements (sent with Medicaid application) clearly showed where all her $ was going (to pay for IL) and showed a steady decrease in assets with nothing different or unusual. Even then, I had to go to her bank and have a bank officer do a detailed letter of all accounts, CD's etc. closed and where the assets went for 3 years prior. Fortunatly all closed went into her single checking account, so this was simple but took about 3 hours at the bank and I went prepared with my legal and all her account info. This letter was submitted with her initial application which ran over 100 pages of required documentation. Is it a total PIA? Yes, but every day I am grateful that the Medicare and Medicaid program exists as there is no way she or I could pay or provide the level of care that her NH provides for my mom, who has Lewy Body Dementia. Imho, if they live long enough (my mom is mid 90's) they will eventually run out of $$ and the caregiver will run out of ability (and humor) and thank goodness there is Medicaid for them available.
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Just be grateful you don't work for the NHS, love.

Actually I do sympathise. But what you, in return, need to recognise is that the dumping granny at the ER strategy is the last resort, often after years of her being turned away from other options because she's being looked after at home. Then her husband dies, or her child dies, or the caregiver breaks down in some other way...

Plus, you talk blithely about the children's having had years to plan their elders' care. HA! See if you can count the number of people on this very forum whose elders turn purple if anyone so much as breathes the word "plan." The children are not responsible for planning their care. The elders themselves are. They're the ones who've had the most advance notice and the authority to act. Why aren't you blaming them?

You see a similar dumping phenomenon with rescue animals, too. Most times the owners who abandon them are just callous irresponsible bastards. But sometimes there's going to be a heartbroken, grieving family in the background, whose circumstances mean they can't any longer take care of their beloved companion animal. Not don't want to, note. Can't.
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IF her doctor is willing to say that she cannot care for herself, she can be admitted to a NH with his orders. Some bring their family member right after a doctor visit when the doc does a history and physical for admission to the nursing home. I wish you the best in taking care of your mother.
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My mother was fist admitted to the hospital when she kept falling. I toldher socia worker she was getting worce that I anted her to get 25 hour care I found a facility for her thats ho my mom got admitted to nh permittly because she was too difficult to take care of. either talk to her Droctors or social workers if your mom ha one tell them the situation. shop around for a good nursing home rehab first that's hat I did. my mom had acase orker through socail services for her being on medicaid global options and adult protecive sevics how that happened as mymom was living withmy nephew he negelcted her I took her out of bad situation.
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My mother went to a nursing home permanently, directly from her home. I did not have medical power of attorney, or any other power of attorney. She had been paying caregivers, and when the money went down to Medicaid eligibility limits, I contacted the nursing home. Her doctor wrote orders. Someone, I can't remember who, contacted the Area Office on Aging, who came to evaluate her Activities of Daily Living, one day, and the next day I admitted her. It was the hardest thing I had to do. Since your brother is still living in the home, this could create problems. I had belonged to the Alzheimer's support group, and they were of great help. I had people who were on my side, and I had people who thought I was the worst person in the world. But, for me, I only pay attention to people with initials before or after their name, such as MD, PHd, LPN, RN, LSW, or someone in authority in the Church. You can contact the Area Office on Aging yourself. If you can't find the number, you can get it from the nursing home you plan to take her to. If the Office on Aging knew just how cluttered, and possibly dangerous it is at your mom's house, maybe there is something legally they can do. Is your mom on the waiting list? When you want to take her there, there may not be an opening. In the meantime, I would try to get more caregiver help. I realize that it will be awkward with your brother there, and he may be giving you trouble, but you need help. And they have seen clutter.
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I am an ER doctor. It never ceases to amaze me at the number of people who bring their family member(s) to the ER expecting us to care for them when “I can’t take care of them anymore.” Have you made ANY preparations for their long-term care? No? Then how do you expect me to magically produce an available nursing home bed at 11 pm on a Saturday night? You have known that you probably cannot care for your family member FOREVER. You have probably had months or years to make preparations. Have You? Have you visited and filled out applications to ANY long-term care facilities? Have you evaluated the costs of long-term care and looked at any of the finances available to your family member? And I often hear “you need to put mother in the hospital for three days so that she can go to a nursing home.” More and more cost restrictions are being placed on the medical system (Me) in this specific area. Do you understand that Medicare and Medicaid and most private insurances will not pay for a three-day hospital stay just because “I can’t take care of them anymore”, “she is falling all the time”, “she won’t take a bath or shower”, “he won’t eat”, “I have a job and can’t be there all the time”? I am happy to evaluate your family member for an EMERGENT medical need that MAY require hospitalization. But don’t curse me when I tell you that you will have to take your family member home because they do not meet admission criteria. Hospitals are not hotels. We cannot just check someone into a room and wait for a nursing home bed to become available. The hospital does not have a magic bank account that will pay for all of these services. You may be PERSONALLY financially responsible for these things. Take the advice of many of these posts. Prepare NOW for when these services will be needed by your family member. Cursing me, threatening me and writing letters to the hospital administrator will not help you or your family member.
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