Quick review of Medicare Skilled Nursing Facility qualification requirements (the last item has not been mentioned in previous posts): 1. The patient must be an admitted hospital patient with at least three overnights of in patient hospital care. 2. The patient must require skilled nursing services ordered by a physician. 3. The patient must enter a Medicare participating facility. 4. The patient may qualify for Medicare coverage if admitted to the nursing facility within 30 days of hospital discharge for the same condition for which they were hospitalized.
Wondering why hospital didn’t release her directly to rehab? My dad has been down this route several times. Any hospitalization causes a big setback for him in his physical abilities and causes a need for rehab. The hospital social worker finds a rehab facility with an open space and he is directly transferred there, generally for the 21 days Medicare allows. How was this need missed by hospital? Can you contact her doctors about this now?
Call the discharge department today and find out if she is eligible for rehab. She would need to have been an admitted patient for 3 days. Observation status doesn't count.
Otherwise, take her to her PCP and get home health care and PT ordered asap.
Weekend hospital staff is usually slack and do the bare minimum. An elderly person QUICKLY loses strength when they lay in the bed and do not move around.
Pray that she gets readmitted. And the medicare rule is that she has to spend 3 consecutive midnights in the hospital to qualify for an inpatient rehab facility. Make a LOT of noise in favor of her going to rehab both to her and the discharge planner. Talk to DP in private and tell them she is demanding to go home and has no support there and that you and spouse work full time and there is no money to pay for sitters, etc. Say whatever you have to say to make them send her to a rehab facility or you will end up looking after her and it is HARD WORK looking after a bedridden adult!
If everything described above plays out and she does go to rehab, STRESS to her that she has to work hard and get strong enough to walk with a walker to have any chance of going home.
She was in the hospital from Tuesday and released on Sunday. She had a stomach blockage and a tear in her stomache. Up until now she has been able to slowly get around to go to the bathroom herself and say get up to make herself coffee. She refuses to do anything else to build her strength up. When we got her home Sunday it was enourmous shock that she wasn't capable of even standing on her own. Maybe we seem stupid. But the hospital didn't say anything and my husband is a contractor that is trying to keep an enourmous job running and we also have 3 kids at home, one graduating. So all of this is new to us. My husband is getting ready to go call the Hospital discharge, thank you for recommending that and we weren't able to get an appt with her pcp until Friday. We did that yesterday. We're going to keep calling the pcp to see if any sooner appts open up. I'm so upset the hospital did not recommend rehab. But this is a learning exp. And I know we need to be her and out own advocate. We also had a call in to social workers and they were supposed to call the surgeon that looked at her but we haven't heard back from them either.
I’m with Countrymouse. I think there's a piece missing here. If Mom was released into your care, didn’t you have any contact with the hospital social worker, discharge planner, doctor, nurses, or anyone else? It was a surprise to you when you got her home on Sunday and she was unable to do for herself? I have the funny feeling Mom refused rehab, and I’m surprised you weren’t told that either, and also that nobody at the hospital, if they knew your situation, approached you about home health care. Perhaps Mom told them she was going to a home with 2 adults and also young adults and that they would help her, and they took her word for it. The problem now is that Mom will have to be readmitted and that could be tough since she was deemed well enough to be released. She can’t just go back to the hospital and have a redo. If she’s not formally admitted, Medicare won’t pay for rehab.
In all my husband’s many hospitalizations, I have always sat with the staff who were caring for him and given a rundown of what he would need before discharge. There were no surprises. Home health care was ordered and durable medical equipment was arranged for delivery before he got home. However, my husband was very amenable to all this and I was there every day and available for any conversations needed about his current or future care.
WeNeedHelp, check your Mom-in-law discharge papers to see what information is given.
I have a feeling, also, that your Mom-in-law refused to go live in Rehab, but she may have said she will have physical therapists come to the house. See if in the paperwork there is a list of at-home therapists for you or her to call to set up appointments.
I went through something similar with my Dad after he left the hospital. Since Dad and Mom were of clear mind, they made the decision that Dad would not go live in Rehab until he regained his strength. I knew nothing about this until a month later. Mom thought she could make Dad well again, that was her "job". Much to her surprise it wasn't working. Oh really??? My Mom was in her 90's.
Hospital should have assisted you with setting up rehab and/or formulating some kind of plan for a person in the condition you describe. I'm amazed that you were able to get her in the car to bring her home. That being said, many people are also discharged from rehab before they really should be - but at least it's a little better than being booted from the hospital with no support. Sounds like the right hand did not know what the left hand was doing at that hospital and your loved one slipped thru the cracks and got discharged home instead of rehab. I supposed it's possible she refused rehab, but I would think hospital would have made some waves with the family if that were the case. You said you have a call in to social work & that's fine, but it sounds like you have a serious safety risk on your hands in the immediate future, so you need to stay on the phone and keep moving up the chain until you get someone at the hospital who knows what to do.
Take it from someone who has been through the whole "loved one in hospital and refusing rehab" multiple times in the past year, she VERY LIKELY refused rehab or LIED and told the discharge planner she was going home with family and would have multiple family members helping and looking after her. Medicare will pay for home health. Get the maximum amount of assistance you can get. Whatever you do, do not DARE lift or pull on her dead weight, no matter if she has fallen or what. The last thing in the world you need is a back injury! Get with the discharge planner again and find out what all she is eligible for regarding home health, durable equipment - wheelchair, hospital bed, shower seat, etc.
And the next time she is in the hospital, and it sounds like it will be soon, DEMAND to speak with discharge planning and communicate that under no uncertain terms are you available or equipped to take care of her.
1. The patient must be an admitted hospital patient with at least three overnights of in patient hospital care.
2. The patient must require skilled nursing services ordered by a physician.
3. The patient must enter a Medicare participating facility.
4. The patient may qualify for Medicare coverage if admitted to the nursing facility within 30 days of hospital discharge for the same condition for which they were hospitalized.
Who signed for discharge?
Call the discharge department today and find out if she is eligible for rehab. She would need to have been an admitted patient for 3 days. Observation status doesn't count.
Otherwise, take her to her PCP and get home health care and PT ordered asap.
Weekend hospital staff is usually slack and do the bare minimum.
An elderly person QUICKLY loses strength when they lay in the bed and do not move around.
Pray that she gets readmitted. And the medicare rule is that she has to spend 3 consecutive midnights in the hospital to qualify for an inpatient rehab facility. Make a LOT of noise in favor of her going to rehab both to her and the discharge planner. Talk to DP in private and tell them she is demanding to go home and has no support there and that you and spouse work full time and there is no money to pay for sitters, etc. Say whatever you have to say to make them send her to a rehab facility or you will end up looking after her and it is HARD WORK looking after a bedridden adult!
If everything described above plays out and she does go to rehab, STRESS to her that she has to work hard and get strong enough to walk with a walker to have any chance of going home.
In all my husband’s many hospitalizations, I have always sat with the staff who were caring for him and given a rundown of what he would need before discharge. There were no surprises. Home health care was ordered and durable medical equipment was arranged for delivery before he got home. However, my husband was very amenable to all this and I was there every day and available for any conversations needed about his current or future care.
I have a feeling, also, that your Mom-in-law refused to go live in Rehab, but she may have said she will have physical therapists come to the house. See if in the paperwork there is a list of at-home therapists for you or her to call to set up appointments.
I went through something similar with my Dad after he left the hospital. Since Dad and Mom were of clear mind, they made the decision that Dad would not go live in Rehab until he regained his strength. I knew nothing about this until a month later. Mom thought she could make Dad well again, that was her "job". Much to her surprise it wasn't working. Oh really??? My Mom was in her 90's.
And the next time she is in the hospital, and it sounds like it will be soon, DEMAND to speak with discharge planning and communicate that under no uncertain terms are you available or equipped to take care of her.
See All Answers