Mom has dementia, is on Medicaid and is in a nursing facility post knee surgery getting rehab. Should she stay there after rehab in LTC?

Hi Anitanita17
Welcome to the forum.
How is your mom doing with the rehab? Is she able to do the therapy?
You need someone to answer that has experience with this. I’ll just ask a few questions and bump this up for them to see.
From what I have read on this forum there are several qualifying factors. Financial and medical need have to be established. The Medicaid she is on is community Medicaid I’m assuming? Would her doctor agree that she needs 24/7 SNF care?
The facility has to be willing to take Medicaid pending and must have a bed in their LTC available.
Then there is whether mom is willing or if you have POA to sign her in?
Those are all issues I have read on here that are considered for LTC placement.
How long has your mom been in rehab?
I personally wouid think you need to talk to a SW soon as it would give you more time to work out the details before the discharge date which can come up quick if mom isn’t able to do her therapy.
Hooefully someone with this experience will answer soon.

It sounds like mom would be considered competent, in early stages of dementia that is the case. Meaning you cannot legally make decisions for her even if you have POA. Mom has the legal right to make her own decisions. A doc would have to prescribe some sort of long term care, would that be able to happen? Is mom not capable to live on her own?

California laws are very different about long term care. You should talk with an elder law attorney about what California requirements are. And the social worker, if there is one, at the rehab facility.

Does she need Skilled Nursing that the Nursing Home/Rehab provides? If no then most likely she would not be able to remain. Memory Care is another thing as is Assisted Living.
Senior Housing might be an option for her at this point if she can live on her own. Or if she can not live alone then the options would be Assisted Living or Memory Care if her dementia is at that point.
Contacting a Social Worker where she is now might be a big help an Elder Care Attorney is another option for you

Does your mother live with you or does she live in her own home?

Whatever you do, do not allow the discharge team to cajole you into becoming her primary caregiver or organizing her care. You are not her nurse. Your mother's needs are only going to increase and, at some point, she may need 24/7 care.

No one can care for someone 24/7 without it taking a huge personal toll. Even babies don't need 24/7 care and grow out of needing feedings every 2-3 hours. Unlike with babies, there is no end in sight - except death - in caring for someone with dementia. And many caregivers die before those for whom they are caring.

Anyone who tells you that caring for an old person with dementia is like caring for a baby is delusional. Talk to the social worker sooner rather than later.

After a long search, a friend of mine found a religious group that ran a little nursing home. They had maybe two dozen residents or so and accepted Medicaid. The place was simple, clean, and the staff was friendly. She placed her older sister with them after the money from the sale of her sister's home was spent and she no longer could afford the nice nursing home. Cast a wider net if you have to. You may be surprised at what's available outside San Francisco, which is outrageously expensive.

So CA does have some very particular programs and rules when it comes to elder care and Medicaid (medi-cal?) which is not a bad thing because I think there are opportunities that don't exist everywhere. But I am not familiar with CA specifically so can't advise on that, however I would think that the fact she is already on Medicaid takes care of a lot of the leg work and uncertainty so it shouldn't be too hard to find out what is available to her. Next I would urge you to be up front with the Rehab facility sooner rather than later, she is already there correct? Just because they have a place for her as a short term knee rehab patient doesn't mean they have a place for her on a more permanent basis, it doesn't mean they don't but it probably takes some planning and the way insurance Medicare/Medicaid in this case covers the two types of care and placements is different too so her current status there doesn't necessarily mean she will qualify to stay. Talking to them about this possibility now gives everyone a chance to investigate, plan and prepare for the barriers and options. Let them know what her current living situation is and what you can and can't provide moving forward, maybe they should or can be evaluating her for things they wouldn't normally given her current reason for being there and their expectation that she was whole coming into the knee surgery and the goal is to return her to that place.

There is nothing wrong with recognizing that a change either needs or will soon need to be made in her living/care situation and that this might be the best time to make it. While you might not have made it this quickly has she not needed the knee surgery, you are where you are and as we see on this forum everyday change in living situation can be very hard on our elder LO's and the fewer changes the better for them and for their caregivers. Adjusting to this hospital/rehab/facility residence and then back to home and back to a facility in the next 6 mos, year or even 2 could be much harder on her than making some form of her current surroundings (a care facility) long term, particularly if she is able to stay on the same campus at the same care facility since you (and hopefully she) seem to like it and it's familiar to her.

Hi everyone. Thanks for your answers. I have read them carefully.

I contacted the Social Worker at the facility -and asked to speak with her next week. I know my mom will be in the facility for a little while longer (she's got a 6 week regimen of IV antibiotics along with rehab, so we have a little time.) and she's only been there a little over a week. She is doing well with PT. She is still kind of shaky walking with a walker. She has to take her medication daily and forgets to do so correctly which has caused episodes of increased confusion, etc. She also has overall physical/mobility limitations due to arthritis and can't do things unassisted - like take a bath. She also can't always remember how to do daily activities - like use the stove. When my dad went to the hospital, she was afraid to sleep at home alone, didn't sleep, and had her first episode of serious confusion/wandering in the hall of her apartment building where someone found her. Since then, someone stayed with her overnight and she started getting sleep again, which regulated her. But post surgery, she seems to have more episodes of being unclear about where she is. So now, I am trying to figure out how to best honor her wishes as her POA, since she doesn't feel able to stay at the apartment we rented for her anymore.

I believe that she is 'community medicaid' and I am pretty sure her doctor would agree that she needs 24/7 care. We'll see how it goes with the social worker - so far we've only been speaking with her case manager. Thanks for the advice, everyone.

I’m trying to figure out why she was given the ok by dr to have surgery when she was in cognitive decline. Dementia patients don’t cooperate with physical therapy. Long term stay at SNF sounds like best idea. Knee surgery is especially difficult even for patients who are physically and mentally fit. The dr who approved this should be ashamed of himself but he obviously has no conscience. Dementia patients also start falling so chances are the new knee will need to be replaced again. Too bad you didn’t research or get more opinions about this unnecessary knee surgery. Hugs 🤗

Have her evaluated while in rehab. Hopefully, there is a LTC connected to the rehab. You can have her tansferred over. This would be the time to do it.

The staff should Know what Is right as Pro Professionals but...Get this Social Worker Over There with a Care INVOLVED NOW.

Remember none of these places are a holiday inn! Nothing beats living with a loving family.

I had the same issue. My mom was in an assisted living facility and doing rather well but she fell and broke her hip. She came through the surgery ok but due to her osteoporosis, her hip joint never healed. So she is in a wheelchair all the time now. There was no way for her to return to her assisted living apartment and her dementia was getting worse so since the rehab is connected to a long term facility, I would take her for walks over to the long term care area. I observed a lot and felt the care the residents were receiving was very good so I made arrangements to get her a room there and keep her there. After being in rehab for two months, she forgot about her apartment anyway and so it was an easier transition. I am very relieved that she is being taken care of.

If she is not safe at home
If you can not safely care for her (and this is your safety as well as hers)
You should discuss the options with the Social Worker.
There are things that may delay her getting accepted where she is now, are there beds available? Is this particular facility a "good fit" for her?
Now is the best time so the Social Worker can do his or her job and get your Mom to a place where she will be comfortable and safe. Does she need skilled nursing like she would get in a Nursing Home or does she need Memory Care at this point?

Your mother's safety and quality if life is paramount. Have her thoroughly evaluated to see where she is with dementia. She can also get the meds to help her. My mother has cerebral atropy which has progressed quickly. But we have her medicaid living choices assisted living and she's doing very well, happy, eating and sleeping well. And she's on very minimum meds. It's difficult to make tough decisions for our parents, but safety and quality of life for her is so important.
Blessings

Talk to them NOW. Tell them that she is not safe to return home, has no one to care for her and you need help with what to do.

They will probably try to bully, guilt, force, demonize and a 1000 other wretched things to make you become her caregiver, don't buy into it for one second. You are not a safe release plan, period. Say it as often as you need to, I am not a safe release plan.

They are paid to help her remain safe, be the squeaky wheel and get it sorted out where she goes next.

Ps, waiting until rehab is over, is to late it doesn't give them any time to sort and figure things out. Respect that it takes time and mom isn't the only person on their plate. They will be easier to deal with if you give them as much time as possible to do their job for mom.

I found not going to the rehab facility until everyone had gone home at 5pm kept me from getting the "you need to take care of him, it's your dad, yadda, yadda, yadda!" Just and FYI.

Talk her doctor first. He can probably help you make the transition from rehab to long term. She is currently in a rehab bed and this particular facility may not have an empty long term Medicaid bed, so I would not wait until the last minute to figure out what happens post-rehab. And yes, once she reaches what they call a plateau in her rehab progress, her chart notes will show she is ready to be released from rehab. It is likely they will say her release date is XX day and someone will have to go get her. I will add this, though. How often are you going to be able to visit? Nursing homes can be a total nightmare when there is no family paying attention to what is going on. Urinary infections are very common and create mental confusion -- and it is common for staff to just write it off as her dementia getting worse instead of treating the problem. Someone needs to observe how meds are given because incorrect medications are common, too. Then there is the problem of her becoming argumentative about a legitimate issue and drugs are added or increased to shut her up. Diapers are commonly used because it is easier to change a diaper several hours later than to go help the patient when they push a call button. The diaper thing is very hard to reverse back to toileting once they start it. With all this said, long term might be in her best interest, but someone has to be proactive in what goes on in any facility.

Anita, if the current facility has rehab & also is a NH and has an open LTC Medicaid bed for her, id really really suggest that if the NH will transition her in as “Medicaid Pending”, she stays there.

Her being in rehab places her in the window of opportunity to transition to LTC & she will have the fat medical chart to support that it’s needed and done for continuity of skilled nursing care. You want to stress that for her safety and security she would need oversight and that is NOT something you can provide, and imho you want to start dropping these points now. Really ask your NP friend on this, perhaps role play with her how to answer questions that may come at you.

also regarding the “window of opportunity”, there were a couple of posts last year that for CA LTC Medicaid program, aka Medi-Cal, the elder had to, yeah had to, go the route of coming into a facility via a post hospitalization rehab placement. Which is exactly what your mom is. The moving into a SNF/NH coming from home or IL or AL, in & of itself would not be enough to get past the initial medical “at need” requirement of LTC Medicaid. They had to be there post hospitalization as there is the documentation to show in detail with various ICD-10 codes as to what care needed. Also both the hospitalization and rehab are being paid by Medicare with her community based Medicaid enrollment paying any secondary costs. Medicare pays like double or triple the day rate for rehab (verses LTC Medicaid), so right now the place is beyond happy to have your mom there. Now she will need to apply for LTC Medicaid (it’s a different program within the huge overall Medicaid budget for your state). But if she’s already cleared community based Medicaid, her eligibility probably should not be a huge an issue as her financial “at need” documentation is in CA system. Still some paperwork to be done but I’d guess her LTC application is fast tracked for approval.

Keep in mind that right now as she is on Medicare benefit, the first 20/21 days of rehab are 100% paid by Medicare. As such she has no copay due to the NH/rehab. Her monthly SS $ or other income is still hers to keep but she really should not have over 2k as an end of the month balance. If she does for LTC Medicaid it will mean she has to do a spend down to the 2k max of assets for an individual (for how most states run LTC Medicaid). If she’s still “progressing” in rehab, after day 20/21, then it’s 80% Medicare & remainder 20% should be paid by her community based Medicaid. The 20% is fixed rate, abt $185 day.

But once out of rehab & onto LTC Medicaid bed, she MUST do a copay or her SOC (share of cost) of basically all her monthly income to the NH starting the day she’s butt in bed for LTC Medicaid.

You need to pay attention to the math....
Say your mom has a small set aside of $, like 1K either in a savings account or a checking account for emergencies. & mom gets $1200 a mo SS. On 4/20 she moves out of rehab as no longer “progressing” & onto LTC. She has to do a copay of last 10 days @$ 40 of April SS$ to the NH = $ 400.00. You as her dpoa kinda need to make sure that the copay is paid. The $800 left over from April SS$ can go into her bank accounts that has the 1k, so she ends her month at $1800 in assets and under the 2k max allowed for LTC Medicaid. If your mom might be over the 2k EOM, find things to spend down on now for her. What depends on how much $; it it’s way over 2k, probably a preneed funeral & Burial is simplest. FH will know what to do & that’s Medicaid compliant. If it’s just a few hundred over, buy extra eyeglasses, hearing aids, shoes and clothing that is easy to put on & can take heavy duty laundry machines.

I’d be concerned that if you take her home & like 4 mos from now, her care needs are beyond your ability, that she cannot get into a NH if the standard for being “at need” is based on continuity of care via facilities (hospital to rehab to LTC) route.

Since your mom is already on medi-cal, her coverage INCLUDES long term care. She should not have to apply for anything and moved into a facility with “Medicaid pending”. Also you don’t have to go from a rehab to a LTC in order to qualify, maybe that was the case at one point but it isn’t the case now. All she needs is her doctor to order long term care. Basically LTC just has to be medically necessary.

my FIL is on Medi-cal and is going from the hospital straight to long term care as soon as they find him a medi-cal bed. He did not need to apply for anything because LTC is covered by his medi-cal. My husband’s grandparents also went straight to LTC after hospital stays and they were on medi-cal.

I live in Riverside County in California. There is another resource that has helped me a lot. Call your County Office of Aging. They may be able to give you some ideas. I also agree that a Elder Law Attorney may help you, and I don't think you should wait until the last minute.

That would be a good plan for her to go to the LTC unit of the NH, but the NH sets the rules. At least they did with my late mother. She was in rehab unit of NH - we wanted her to go to LTC unit of said NH - no go - they had a family meeting saying she was too well to stay at NH -WRONG ANSWER!! She had a stroke there 48 hrs later & died.

Hi everyone,

Thank you all for the thoughtful and detailed responses. It gave me enough information to move forward to a good outcome. I contacted the consultants who helped them apply for medicaid and asked for advice. They also gave great advice and is ready to change my mom's medicaid status. I looped in the care manager in an email thread to ask for her help in figuring out next steps for my mom, and the case manager said that she expected that my mom would just stay at the care facility under LTC medicaid, since my dad had been there for a month under long term medicaid. So it seems there is a bed for her after all. Thank you igloo572 for your explanation about how my mom was in a 'sweet spot' in that she had been admitted into rehab from the hospital. I followed up with out medicaid consultants who fleshed this out for me and will help me make sure that their paperwork/share of cost is handled/calculated after she is 'out' of rehab.

I probably won't believe it until the paperwork is signed, but I am hopeful. It doesn't really end, does it? Now I'm worried about them kicking my mom out because she has angry moments when she gets confused (not violent), but I'll just keep taking it one day at a time. Thank you all.

Thanks for letting us know they found a bed!
That’s great.