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Hi,

Around June of this year I became my 93 year old grandfather's primary caregiver. He has Alzheimer's dementia, bladder cancer, a relatively recent below knee amputation. He'd been (and still is) living with my mother, who has (non-durable) POA over him (I am second in line). My mom's physically disabled herself, so when he had his leg amputated, I knew she'd need help with him as he would take some time to become ambulatory again, if he ever would.

My husband and I decided that the best thing to do would be for me to quit my job and temporarily relocate to fill in any gaps in care.

I've been doing this for 24/7 for the last five months. I know I cannot do it much longer.

I have plans in place to move both my grandfather and mother back to my city of residence about a month, so that they can both be looked after, and so that I can have some support from my husband.

My problem is, I can't seem to get any non-contradictory answers about gaining admission to a nursing home for my grandfather. I was told by a social worker that his monthly income was too high (w/ SS, VA Benefits, and Gov't Pension, it's just about $2700 after all the healthcare premiums come out) to qualify for Medi-Cal (the state of CA's medicaid program) and that we'd essentially have to "dump" (seriously, her words) at the hospital after a hospitalization, saying that we couldn't care for him, but were willing to apply for Medi-Cal.

Another person I spoke with (an attorney who helps families w/ assets qualify for Medi-Cal) sort of confirmed this; he said that the only reason that my grandfather doesn't qualify for Medi-Cal is because he's not ALREADY in a nursing home. He suggested we pay privately and simultaneously begin an application for Medi-Cal.

Yet, a nursing home administrator I spoke with last week said that he probably DOES qualify already and that I should put in an application. I did, to cover all of the bases, but I'm becoming increasingly confused and frustrated (which I'm sure you all know is all too easy when you're trying to just make it through the day and give the best care possible!!!).

My husband and I are really not in a position to pay privately, even for a few months while we wait for Medi-Cal qualification (he's a teacher, and I was just a part-time civil servant). I don't have any other family who can help, either.

I am already battling feelings of guilt about even considering putting him in a nursing home, but, when I see how caring for him has impacted my mother's health, I know that I probably don't have much of a choice. I really want my grandfather to get the best care possible and, although I've been able to learn to give him pretty darned good care--I am not enough. (Yes, we have in-home "support" but that amounts to about one hour a week; I've heard that hospice programs provide not much more...)

Is there a way to gain my grandfather admission to a skilled nursing facility if we are both unable to pay privately and he doesn't currently qualify for state aid?

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Are there any veterans facilities in the area? Call and talk with them they have a variety of programs for vets based on income.
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Flo - well in a way all 3 are right…it's the Medicaid Maze of Hell.
for # 1 the caseworker - his income is $ 2,700 a month, right? WIth the insurance, it probably is closer to 3K a month, I bet. Now Medicaid is run by each state under an overall federal guideline, so each state puts it's own spin on the rules. I don't know what the exact ceiling for income is in CA, you need to find that out. Most states have their income @ 2K. Like for TX (my mom is in TX), the income ceiling is $ 2,094.00 so if you get $ 3,200 a month, you do NOT qualify for Medicaid as your income is too high to be "at-need". But all hope is not lost if that is the case, if the income qualifies (SS, most federal retirements) it can be diverted to a Miller Trust. So the Trust gets the excess income ($ 1,106.00) and so now Dad is OK for Medicaid. Miller has to be done by an attorney so that it is flexible, adaptable and OK for legal in your state.

What she meant by the "dump" is that the hospital would have to do a placement for skilled nursing or rehab after the hospital discharge to a NH facility…..when this happens after a 3 day hospital stay is that the first few weeks @ the NH are paid for by Medicare (MediCARE not Medicaid). This stay can be up to 100 days -which I've found is rare - most stays are 3 weeks and then they aren't progressing enough (like with their PT or OT) so week # 4 is the transition week to get them to continue in the facilty as "Medicaid Pending". You apply for Medicaid to pay for their continued stay @ the NH & get with legal to set up Miller, etc.

for # 2 - where I think he is going is that he can tell that there will be issues with gran's funds…. (BTW does grandpa have assets….anything more than 2K in non-exempt assets will have to be cashed in, sold or spent down?. Did the attorney see something there that needs to have this done, and this would be what would private pay for granpa's NH?) I bet the private pay is to do a spend-down to get grandpa impoverished. If you go this route, I really really really want to stress that grandpa go into a NH that takes residents "Medicaid Pending". The application process can take a while (my mom's was almost 6 months) and there was no way for her or us to ever private pay. You want it to be that the NH is OK with only getting grandpa's income co-pay while his application runs it's course. Whatever you do, DO NOT sign the contract to be financially responsible, you have to sign everything.."Jane Smith Jones as DPOA for George Smith" or get gran to sign.

Has anyone explained the co-pay? It is called different things in each state, like "resident responsibility". How the copay runs is like this, my mom gets $ 800 in SS and about 1K in my late dad's retirement, her monthly income is $ 1,800 a month. Now state of TX has a $ 60 a month personal needs allowance. So each month my mom has to pay her NH $ 1,740.00 in her income for her co-pay. If any of grandpa's income has been used to pay for your mom's needs, that $ won't be there anymore. It basically has to all go to the NH.

for # 3 - if grandpa is still @ home, then the NH is going to need have to have him evaluated to see if he qualifies both medically & financially for Medicaid. Medicaid qualifications are both medical AND financial. When they come from a hospitalization, the medical file & doctors orders are there to show the need for skilled nursing care, so no need to do this; when you are private pay, they don't really care what level of care you need as long as you are paying, you are in. But as grandpa is neither of these, he has to apply to the NH so that the NH can do an evaluation to make sure he will qualify for needing skilled nursing care. I moved my mom from IL to NH and bypassed the AL stage and it meant having her go every 4 - 6 weeks to see a gerontologist so that she was creating the thick medical history to show her increased need for skilled nursing care. The visit in which she had a more than 10% weight loss and critical H & H lab, he wrote the orders for skilled nursing care needed. The NH needs you to apply so they can do a work-up and get his records, etc.

With all the issues he has, I bet he will qualify for hospice. Have you looked into that? In a way getting him on at-home hospice (MediCARE pays for hospice) would be good in that you get extra help in the near term, and then you can then get him placed into a NH that the hospice group already goes to. So there would be a continuity of care for him. NH seem to like hospice patients as it provides for extra hands @ the NH. My mom after 2 years in a NH, shattered her hip in June and so now is on hospice @ the NH with a hospice RN that comes twice a week and hospice aid 4 times a week and she got a special mattress and a geri-chair and geribathing chair etc and Medicare pays for this as part o hospice benefit. Now mom's room & board costs @ the NH are paid by Medicaid. I would talk with grandpa's doc to see if they will write the orders for him to get an hospice evaluation done. Compassus and VITAS are two bigger hospice and both are very good. The advantage to a bigger national hospice is that they can get the equipment needed asap - the beds, specialized mattress, chairs, etc are expensive - and they have a larger staff so that if grandpa needs a class 3 or class 4 drug (for dealing with cancer pain) they will have the professional that has the ability to carry those on them and administer the drugs.

It's a lot to deal with and just so much to consider. You have to try to find the time to get grandpa's financial and legal items organized otherwise you will go loco. The medical is kinda out of your hands. The NH should have a list of the items they want to see to accept him Medicaid (or MediCal) pending. Start finding those items and put them in a binder. In January, you should be getting his SS and federal & VA statements, both for what the changes will be for 2014 and for what they paid for 2013. These are SUPER IMPORTANTE so you want to put these in the binder
too. Actually I'd suggest you do this for your mom too as eventually you will be going down the same path for her. Good luck and keep a sense of humor!
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Thank you, JessieBelle, for giving me a place to start. I really appreciate it.
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Your grandfather is a little above the requirements for Medi-Cal. What I would do is see if there is a legitimate way that the excess can be spent down legitimately. I don't know much about monthly Medicaid spend-down. I hope someone else can provide some help here. In your situation I would seek the advice of a Medi-Cal councilor to get some ideas on spending down and starting the application. Life can be harder for the "almost poor" than those who are totally poor when it comes to health care.
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