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My dad is 73 years old. He had surgery about 11 days ago and he had it on his foot which is a foot that is on a paralyzed leg. He uses a brace on that leg. His other leg is a little bit weak but as long as he has the brace on he usually can be mobile and very independent. Since the surgery he's unable to be weight-bearing therefore he is very unsteady. The surgery was outpatient. He's been home and has fallen several times and been taken by rescue squad on two occasions admitted into the hospital for 24 hours and then released. My mom is 72 years old and although healthy she's unable to physically meet all of his needs. Due to medication trauma surgery and the overall situation he's had some big issues with memory and forgetfulness and confusion. We believe he needs to have physical therapy on an inpatient basis but every time he's in the hospital they release him after 24 hours & we go home and it all happens again. What are our options? We live in Omaha Nebraska. He has Medicare and supplemental insurance. My mom and dad do not have any legal documentation such as power of attorney. My dad is very mobile and independent normally so this is not a situation we've ever had to deal with. I basically want to know if he has to be in the hospital for three days in order to go to rehab or can he be admitted to rehab the other doctor or are there other options?

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And yes, if it's in the 30 day window that you switched to an inpatient rehab, and you had a 3 day stay with initial foot surgery, Medicare will pay for costs, (minus deductibles and copays). Recently I was able to help get one of my home health patients changed over to inpatient because the home environment just wasn't working out. He had been on home health for 2 weeks already. The process took about 5-7 days. It also depends on if the facility you are interested in has a bed available, etc. Good Luck.
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Reply to reho31
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You mention your Dad having surgery 11 days ago. If he was in the hospital 3 days back then, I think he still qualifies. I believe he has 30 days to change to an inpatient rehab status, but not certain on that. Call a local Skilled nursing facility that does rehab and ask if they have beds available. Then tell them you are interested in inpt. rehab and they will just need to coordinate with his Dr. in getting the order. I assume if he already has home health PT his Dr. is already involved. You have the option of changing from home health to inpt. rehab if it is within 30 days. But all the steps take time, so I urge you to act today. I have worked in case management with home health, so this has been my experience. Best Wishes.
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Reply to reho31
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The hospitalist will determine if the patient is able to be released to their home. If not, he or she has to ensure that there is a Medicare bed available in the Rehab Unit of the SNF. It will be a good idea to get POA in place.
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Reply to Llamalover47
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I may be missing a point that's already been made, but while his foor is healing, couldn't he rent a wheelchair to use most of the day? When the PT comes, then she/he can teach your Dad what to do to avoid falling. Alternatively, you could borrow or rent a walker. PT would again help him learn how to use it, but if you can't wait, if you know anyone who's used a walker, that person could tell you or show you what to show him. It's not very complicated even if you are confused. (I know from experience!) Then he could transition, with therapy, to his former independent walking practices. Either way, that should cut down the falls.

Having spent quite a bit of time in rehab, I would disagree with making in-patient rehab as the top choice. As others have said, he can fall there, too. Even if he has 4 hr of rehab 2x/day, that leaves quite a bit of time when he may try to get up by himself and potentially fall. And if he's already confused, being in another strange environment is going to confuse him even more. Once PT is ordered, you will probably have someone there in 24-48 hr. I think you shoukd try that route, which has already been prescribed. Be sure if you do rent a walker or wheelchair that the doctor orders it, and that the prescription goes to a medical supply store that's a Medicare provider. You'll still pay, but less. Also pay from his funds. With a lot of medical expenses this year, he might be able to itemize his medical deductions,
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Reply to caroli1
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He can private pay in rehab, as long as they have a room. If he does PT ordered via HomeHealth, then a physical therapist will assess him once an order is written. But normally it’s just a PT assistant who comes and carries out the PTs exercise plan. Then he needs to do them between visits. To qualify for HH, he must be homebound by Medicare definition and can’t leave home except for doctor appointments, church services and getting a haircut. They will dismiss him if they find out otherwise as that is fraud. You could hire private aids to help. But I would think the PT would assess his strength, mobility and whether he needs any aids to help with mobility (walker etc). Your parents need to get a DPOA and MPOA now!
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Reply to Harpcat
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geddyupgo,

Thanks for sharing all of your knowledge.
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Reply to NeedHelpWithMom
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I spent 10 years as a Director of Admissions and 1 year as Director of Guest Relations in a rehab facility and stay current by maintaining my certification as an Assisted Living Administrator and as a consultant to families who are dealing with the issues of care giving.

Medicare rules can be tricky. A 3 night admission to a hospital is the best way to go if you want Medicare to pay. Traditional medicare will pay fully for up to 20 days of skilled nursing (g-tube, wound vac, etc) and/or rehab. If those services are needed after 20 days, there is a co pay of approximately $170/day which should be met by your supplemental insurance. The original rehab stay can be cut shorter than 21 days if Dad won't participate or if it appears that he has reached a plateau in his rehab. You can probably make arrangement to private pay if you want him to stay longer but I'm not sure what the benefit would be as he could still fall in the rehab facility - they would just have the staff there that could pick him up.
The only exception to the 3 midnight rule that I've been able to find is for joint replacement (knee, hip, shoulder) and it took me 40 minutes on the 1800medicare hotline to get this information (blessings upon the CSR who answered my call; she wouldn't give up even though she had to go two levels up in the hierarchy to get the answer!!)- and this surgery can qualify for acute rehab.
Call the Medicare number and see if your Dad's doctor knows any of the admitting staff at the hospital you take Dad to for his er visits. They can be key players in the recommendation for rehab but they have to get on board the train. Good luck.
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Reply to geddyupgo
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cherokeegrrl54 Sep 25, 2019
Excellent information....thank you for taking the time to get it!!
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If he is not weight bearing on one leg then his gait training will consist of hopping on the good leg with a walker. Been there done that and a waste of time in the long run. I second the home health visits with close attention to healing the surgical wound on the foot.
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Reply to Bigsister7
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If home health care is ordered the home health nurse will usually recommend occupational therapy and physical therapy. I encourage you to do both as they work best together.

Please do tell the assigned nurse all health issues because the head nurse (RN) is the one who has the authority to order needed services.

If you can push for a home health aid to help you with bathing as well. This will also be included in Medicare coverage. Any other items needed for care such as a walker, shower seat, raised toilet seat, etc. can be sent to your home either free or at a significantly reduced rate. Take advantage of it if you meet the criteria. Caregiving can become quite expensive. So every little bit helps.

Council on Aging can provide a certain number of respite hours (4 hour shifts) per month if you qualify and their caregivers provide bathing, preparation of meals and light housekeeping for the patient such as laundering and changing bed sheets, vacuuming, dusting, cleaning mirrors, etc. (general light cleaning).
This service is free to those who qualify.
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Reply to NeedHelpWithMom
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There is a three day hospital stay required. They will order rehab stay. Medicare pays for 21 days of rehab care. They also pay for home health after discharged from rehab if it is required.
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Reply to NeedHelpWithMom
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My understanding (and I might be wrong) is that Medicare will pay for the rehab facility, in full or in part, only if it is preceded by a hospital stay of at least three nights. But if self-pay is an option, then the three-night rule shouldn't be a barrier to your dad doing a stint in a rehab facility. Also, it's possible that the supplemental insurance would cover some or all of the cost for the rehab facility. Having something in writing from the supplemental insurer before the stay at the rehab facility begins would be ideal.

Last year ,my 90-year-old mother had knee replacement surgery. She was planning to do rehab at home; I think that home rehab is the default and is strongly encouraged by the physicians and hospital and insurance companies. Surgery went well, she was discharged the next day with my siblings ready to take care of her, but she ended up back in the hospital, via the ER, that evening, because her pain pump came out. She said she wanted to do rehab at a facility instead of at home. The hospital insisted on discharging her after two nights (I'm sure because of the three-nights rule), but my mom was willing to be self-pay if her supplemental insurer wouldn't cover the stay. (The insurer's first answer was ambiguous, then it said no, then it changed to yes.)
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Reply to Rosered6
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Shane1124 Sep 24, 2019
It’s so hard to navigate the system. I believe he will need to adhere to the 3 night stay and then go to rehab. In my opinion inpatient rehab should be ordered as well.

I am not sure dad would be ordered PT as he is non weight bearing on that leg. His rehab sessions should be saved until he can bear weight. They should have instructed him on how to stand and pivot on the good leg to get out of bed & assist himself to perform ADL’s.

I would contact your father’s surgeon if you haven’t already and discuss your father’s care plan going forward. Let the surgeon know that you feel dad would benefit from in patient rehab.

Rehab may depend on his foot being able to weight bear which can take a long time depending on your dad’s co-morbid conditions (diabetes, PVD, HTN).

After this rehab stay, he can be eligible for home care paid by Medicare if a need persists and the patient is home bound. Realize that once he begins any rehab out patient (which he definitely should) he is no longer considered homebound and HC stops.

Good luck!
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Dad should clearly have gone to rehab. Now that he has had a stop between rehab and the hospital things can get complicated as regards medicare. There are hard and fast rules and I once knew one or two of them when I was in nursing. For instance you had to have 3 days hospitalization to qualify for rehab, if I recall. And being RE admitted to hospital before a magic 60 days counted against everything, as well.
I don't even know where to tell you to go with this except the 1 800 Medicare number to see what the rules are. Explain it just as you did here.
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Reply to AlvaDeer
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Call the doc and tell him dad NEEDS rehab! Then check with Medicare to see if it will be covered. Next time in ER refuse to take him home without him going to rehab first. You have the history now with prior discharges that he is not yet safe to go home and you are unable to provide the care he needs until rebuilds his strength.
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Reply to gladimhere
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Call the doc that did the surgery and tell them dad needs rehab! If dad refuses, you most likely will be stuck. Physical therapy can be ordered by the doc and done in the home, but of course will do no good unless dad does the exercises.
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Reply to gladimhere
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Ccfroien Sep 22, 2019
Thank you...do you know if a hospital stay is required or can his doctor admit him to rehab? (He 150% needs it) I feel like he's getting worse...we just brought him home this morning from an overnight hospital stay... He fell three times yesterday and was so confused he didn't even know what day of the week it was but this morning his mental status was better and they felt there was no reason to keep him even though we still have the huge issue of mobility. They did prescribe for PT to come home and help but that is not the only issue. Until his strength is built back up how in the heck are we supposed to take care of him...I just feel so defeated. Thanks again 😊 in advance for your answers.
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