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.
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.
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.
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.
Can the pcp qualify her for the 21 day rehab since she wasn't in the hospital? We just talked to the hospital and they said they would set us up for the home care. I'm honestly saying that no one talked to us about this. The doctor was supposed to call and never did. But we were more concerned about him calling about surgery. Now I am suspicious that she refused therapy. My husband would visit her in the evenings and they released her on a Sunday. She has Crohn's disease so stomache issues are not a new thing. I really appreciate everyone's help in taking their time to write answers. One last thing, should we go ahead and accept the home care through the hospital, or should we wait to see if she can get into a 21 day rehab center through her pcp? Would accepting the home care mess that up in any way?
WeNeedHelp, your Mom-in-law needs physical therapy to regain her strength, and that is so important.
Another time my Dad was in the hospital he opted for Rehab, this time my Mom didn't refuse. Dad said the Rehab was so much better, as he had machines he could use to regain his strength. And he could go to the gym area to use the stationary bike or use the weights. There were enough physical therapists there to keep an eye on him.
What is interesting, my Dad would do better if the therapist was a young pretty woman :) And one time my Mom needed physical therapist, she had a very nice young fellow that Mom would pepper her conversations with how great "Paul" was with her therapy.
freqflyer that sounds like us. Now we know better. I wish to goodness the hospital had explained this to us. My husband and I are having a nervous breakdown. Since we are self employed any loss of work time is very painful and scary. His Mom is one of the you are supposed to take care of and do everything for me mindsets. My husband is an only child and has no other relatives near us. We are what she's got. Thank you again everyone. Super appreciate it.
Unfortunately, WeNeedHelp, live and learn. Sounds like everyone dropped the ball here. Yes, you should absolutely accept home health care/therapy for her. That may be all you’ll get. These people can show you how to care for her. But if she’s one of those perpetually needy people, you’ll both burn out sooner than later and your married and home life with along with it. Hopefully the therapists will see she needs more care than you and they can provide and help you put in for a rehab stay for her.
Now you know, for future hospitalizations, speak up! Good luck with all this and come back to let us know how it turns out.
WeNeedHelp, I would be curious if the physical therapist at the hospital had a chance to work with Mom-in-law. Hospitals like to get the patient up and out of bed as quickly as possible. Thus, use a walker and gait belt for a short walk around the the hospital. It should be noted on your Mom-in-law's chart.
If yes, it is curious why now your Mom-in-law doesn't want to stand or walk. Maybe the medicine is making her feel light-headed or dizzy.
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.
I have a feeling the hospital did us major wrong. I know we don't know what we are doing with major care yet. And I don't like thinking that bc I honor health care people and teachers. Two things I could never do. But we put in a message to her pcp who is also my husband's instead of calling the front desk and he actually just called back. He looked at what the hospital sent him and she actually has major blockage in one of her arteries which could also be causing the major weekness. The hospital had never even mentioned that to us. So she is going to see the pcp this evening. He squeezed us in there. And it sounds like she will be heading to a hospital again for the blockage. We are going to see if she can be refered to a different hospital. freqflyer - my motherinlaw doesn't do much other than sit in her chair and watch her favorite shows. We are used to her not doing much. She came 5 years ago and she sat. We make her do certain things for herself but it has been a major struggle. We're just used to her sitting but she could always walk down the hall to the bathroom using her walker and get up to make herself coffee and use the microwave. She's had stomache issues before due the the Chrohn's. But when she came back she couldn't stand up to get herself up on the portable pot that is right next to her chair. I don't think she's on any new meds. She is super weak. I'm thinking it is a combo of being on a liquid diet and laying around for 5 days and the artery issue is a giant concern that we weren't aware of. How do you look at her chart.....probably by registering online with the hospital. I'm going to look at her discharge papers and see if I can do that. I have a feeling they didn't get her up. She wouldn't have been able to do it. I asked my husband how he got her into the car. He helped her from the wheel chair into the car like he always does. It is always a struggle. We've asked her to excersise, walk around more, she refuses. My husband leveled out the back yard so she could go out and sit from the back door that he put in and she won't. Anyways I'm rambling at this point. I guess I'm not used to having someone to listen to all of this. Hopefully we will have help when she goes in to the pcp this evening. Thank you so much everyone!
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.
Just to show you an example of how the patient and the hospital staff can drop the ball, I have a relative who fell off a porch and broke multiple bones in her back. She raised HELL, telling everyone NOT to take her to the hospital! She had already been in and out of the hospital the previous year and viewed it as a path to the NH.
Well, they did take her to the ER and apparently she threw a big enough fit and the doctors would not admit her to the hospital. Then she wanted family to take care of her. She could barely get up and down and is heavy. None of us would have been able to lift or pull on her. 2 days later, she was in such pain we were able to get her PCP to admit her to a different hospital. She ended up being there for over a week for pain and because her afib was horrible. She tried and tried to get the hospital to discharge her to go home, frequently LYING and telling the Discharge Planner that she had family willing to stay with her 24/7 and take care of her. We each made it crystal clear to the DP that this was A LIE! Long story short, she had about 6 hospitalizations and rehab stints in one year. She is now in an ALF and doing so much better.
NeedHelp, reread Barb's post. Last time I went through this, a patient could be referred for rehab even if discharge had taken place, as long as the referral was w/I 3 days of discharge. I calculate that she would have until tomorrow to get a rehab referral and get in.
At this point I'd go beyond the hospital social worker/discharge planner and go right to the administrator of the hospital. I've done that before when I've had problems. The hospital we used had an ombudsperson to handle issues such as this.
Don't accept home care recommended by the hospital until you've gone through the rehab route. Home care is nominal, and based on experience as well as what you're written about this hospital, I would not be inclined to accept their recommendation.
Start calling the hospital administrator, now, then start investigating rehab companies. Some are excellent (the VNA), some are okay, and some are mediocre. After she's in rehab, ask the social worker there to give you some recommendations as well as brochures from home care companies, make checklists and start calling.
My family member also lied about two key things: She lied about the type of railings she had at home in order to create a scenario which seemed more possible for her to be at home. She also lied that she had neighbors and family who would be with her pretty much all the time. Not sure who all believed her, but in addition to her insurance cutting her off... she was discharged with the belief that there was a solid support system in the home and there wasn't.
Update after reading your latest posts: My advice is already too late, given the arterial blockage, but I'm leaving the post for future reference in dealing with hospitals and rehabs.
Discharge papers typically don't address rehab, at least in my experience. So omission from them really doesn't mean anything. In fact, they typically recommend follow-up visits within a week or two with a specific physician, ignoring the fact that this can be complicated if not impossible for some level of patients at rehab.
Just saw that she's heading back to a hospital; make sure the PCP understands that you want her in rehab, so she needs to be ADMITTED, not just held for observation, for 3 days in order to requalify - IF the 3 day post discharge period has expired.
You can go to ANY hospital you want if the PCP practices there. Explain the situation and tell her/him you don't want to go back to that hospital. Often doctors are admitted to practice at a few different hospitals. If he/she doesn't have privileges at another hospital, explain what happened and ask how to prevent it from happening again. And make it clear you're dissatisfied with that hospital.
With an arterial blockage, your PCP should know which hospitals have good cardiac units, and might even find a way to get you admitted, through another cardiologist, to one with a good cardiac unit.
(To learn more about this, google ":coronary artery disease" and check out the articleson the Mayo Clinic website.)
As to reviewing her chart, you can ask the PCP to get it for you, although he/she might be reluctant b/c a patient's family requesting a chart could infer that they're considering action against the hospital.
You can also request the chart from the medical records department at the hospital. Some hospitals will provide the information for free, others contract this service out. Last time I requested mine just for an ER visit, it didn't arrive from some out of state contractor until a month later.
Best to have your PCP or cardiologist (and I think she's going to need one) review the chart and bring you up to speed.
I don't know but I doubt if any online portal would have all the nurses' notes and charting, so I'm not sure you'd find what you're looking for.
Don't blame yourselves; someone should have discussed the post discharge care with you; sounds like either there were some miscommunications or the discharge planner didn't address this issue, or the hospitalist or attending failed to address the blockage.
I can't imagine anyone discharging someone with a major arterial blockage. Were there any recommendations to see a cardiologist ASAP post discharge?
GardenArtist thank you so much! I have been writing everything down that you told me. I'm trying to find the number to the hospital's administrator to have my husband call just in case, want to have bases covered. My husband just called as I was writing this and said the hospital just called and said they were able to get her into a rehab center. sounds odd as that we had not called above level on them yet. The place they are looking at has 3 stars. Makes me nervouse. Can you ask for a different one? ? My husband is supposed to call the pcp and ask how bad the blockage is and should she not go to rehab or go back to the hospital. I want to make sure the blockage is bad before we lose the chance for rehab. I'm worried that the dr was bringing that up to get her back in the hospital to try and get her into rehab. I take it a pcp can not admit a patient into rehab?
If the patient is not listed as incompetant, they're going to discuss rehab and discharge with the patient, not the family. Unfortunately, you have to camp out at the hospital to be in the loop. I found it helpful to track down the discharge planner and outline the patient's needs and limits. They hear it all, so they're tuned in to elderly patient saying they're fine at home, and the family telling them not so much.
We found that once a patient is in hospital, a hospitalist (not the PCP) takes point. The hospitalist will do the rehab referral, usually after OT and PT have done their evals.
Need help, I'm glad the hospital is now focusing on rehab. Maybe someone "got the message."
You can ask for a different rehab, but I'd highly suggest you check it out first if you can. I made a big mistake once when I interviewed and toured a facility which for all practice purposes looked great. What I didn't know was that the food was inedible, my father's chart was lost, his coumadin wasn't administered and he was close to a level of hemorrhaging when I pulled him out and took him elsewhere.
Do you have any friends who can help you tour the facility? You could quickly locate a local or state ombudsperson and ask if the facility has a good or bad reputation.
Google "ombudsman" for your county, then your state, or even ask one of the hospital staff (who contacted your husband) for the number. Make sure it's stated that it's to check out a rehab center so the hospital doesn't think you're getting ready to complain about them and start circling the wagons.
Linda offers good insight on a hospitalist vs a PCP. Because we'd been through that scenario before, and once it was a terrible situation, I found a PCP who also takes point as attending physician, so the last 2 visits were managed by the PCP instead of hospitalists.
I think various hospitals are in different stages of adapting to hospitalists. My first experience with them was in Ann Arbor, with a well respected teaching hospital. It was years before local hospitals moved to use of hospitalists. Some are good; one stunk - he and his residents were so bad that I actually had to tell one that the questions she was asking were none of her business, and to leave Dad's room immediately. (She was asking how he felt about death, if he believed in a god, and more, and wouldn't he agree that he'd "had a good life" and shouldn't be resuscitated if he crashed - she was way, way out of line.)
Glad Mom is getting rehab. Healthcare is a learning thing. You learn by experience. I learned a lot working as a secretary for a Visiting Nurse association. I am really surprised they sent Mom home without talking to a family member to confirm info. Make sure next time you talk to a SW at the hospital and explain the home situation. In my experience they have never asked if a parent wanted rehab they said Mom was being sent to the hospital and gave me options. I wouldn't suggest home therapy if someone wasn't there other than Mom. These people r strangers coming into your home. Doors have to be unlocked so they can get in.
Just a heads up...sign nothing that makes you responsible for payment. Medicare pays 100% for 20 days, 21st to 100th day 50%. If she has a suppliment they may pay some of it but not all. If MIL has no money other than SS and a pension then tell admitting at rehab Mil may need to file for Medicaid if she is in longer than 20 days.
JennDave is the OP, by the way. :) This is a riveting process for you, you are making good progress, bless you. I hope you are reaching out to any friends that can help you in any way... getting or making food, shuttling kids to their activities, etc. Do let others know you are stressed and could use support. Best wishes.
When you call, make it clear to the hospital that this is an urgent situation and you will be forced to bring your mother-in-law to the emergency department to get the treatment she needs to regain her ability to stand on her own. Hospitals are penalized by Medicare for re-admissions. They are sensitive to that.
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.
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.
Another key is for you to refuse to lift her and move her and possibly injure yourself.
Keep us updated!
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.
Another time my Dad was in the hospital he opted for Rehab, this time my Mom didn't refuse. Dad said the Rehab was so much better, as he had machines he could use to regain his strength. And he could go to the gym area to use the stationary bike or use the weights. There were enough physical therapists there to keep an eye on him.
What is interesting, my Dad would do better if the therapist was a young pretty woman :) And one time my Mom needed physical therapist, she had a very nice young fellow that Mom would pepper her conversations with how great "Paul" was with her therapy.
Now you know, for future hospitalizations, speak up! Good luck with all this and come back to let us know how it turns out.
If yes, it is curious why now your Mom-in-law doesn't want to stand or walk. Maybe the medicine is making her feel light-headed or dizzy.
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.
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.
Well, they did take her to the ER and apparently she threw a big enough fit and the doctors would not admit her to the hospital. Then she wanted family to take care of her. She could barely get up and down and is heavy. None of us would have been able to lift or pull on her. 2 days later, she was in such pain we were able to get her PCP to admit her to a different hospital. She ended up being there for over a week for pain and because her afib was horrible. She tried and tried to get the hospital to discharge her to go home, frequently LYING and telling the Discharge Planner that she had family willing to stay with her 24/7 and take care of her. We each made it crystal clear to the DP that this was A LIE! Long story short, she had about 6 hospitalizations and rehab stints in one year. She is now in an ALF and doing so much better.
At this point I'd go beyond the hospital social worker/discharge planner and go right to the administrator of the hospital. I've done that before when I've had problems. The hospital we used had an ombudsperson to handle issues such as this.
Don't accept home care recommended by the hospital until you've gone through the rehab route. Home care is nominal, and based on experience as well as what you're written about this hospital, I would not be inclined to accept their recommendation.
Start calling the hospital administrator, now, then start investigating rehab companies. Some are excellent (the VNA), some are okay, and some are mediocre.
After she's in rehab, ask the social worker there to give you some recommendations as well as brochures from home care companies, make checklists and start calling.
It is very common for elders to give what they believe is the "correct" answer to health professionals' questions, rather than the truthful answer.
Some health professionals are more aware of this phenomenon, and more careful to probe a little, than others.
Discharge papers typically don't address rehab, at least in my experience. So omission from them really doesn't mean anything. In fact, they typically recommend follow-up visits within a week or two with a specific physician, ignoring the fact that this can be complicated if not impossible for some level of patients at rehab.
Just saw that she's heading back to a hospital; make sure the PCP understands that you want her in rehab, so she needs to be ADMITTED, not just held for observation, for 3 days in order to requalify - IF the 3 day post discharge period has expired.
You can go to ANY hospital you want if the PCP practices there. Explain the situation and tell her/him you don't want to go back to that hospital. Often doctors are admitted to practice at a few different hospitals. If he/she doesn't have privileges at another hospital, explain what happened and ask how to prevent it from happening again. And make it clear you're dissatisfied with that hospital.
With an arterial blockage, your PCP should know which hospitals have good cardiac units, and might even find a way to get you admitted, through another cardiologist, to one with a good cardiac unit.
(To learn more about this, google ":coronary artery disease" and check out the articleson the Mayo Clinic website.)
As to reviewing her chart, you can ask the PCP to get it for you, although he/she might be reluctant b/c a patient's family requesting a chart could infer that they're considering action against the hospital.
You can also request the chart from the medical records department at the hospital. Some hospitals will provide the information for free, others contract this service out. Last time I requested mine just for an ER visit, it didn't arrive from some out of state contractor until a month later.
Best to have your PCP or cardiologist (and I think she's going to need one) review the chart and bring you up to speed.
I don't know but I doubt if any online portal would have all the nurses' notes and charting, so I'm not sure you'd find what you're looking for.
Don't blame yourselves; someone should have discussed the post discharge care with you; sounds like either there were some miscommunications or the discharge planner didn't address this issue, or the hospitalist or attending failed to address the blockage.
I can't imagine anyone discharging someone with a major arterial blockage. Were there any recommendations to see a cardiologist ASAP post discharge?
Good luck, and please keep us updated.
We found that once a patient is in hospital, a hospitalist (not the PCP) takes point. The hospitalist will do the rehab referral, usually after OT and PT have done their evals.
You can ask for a different rehab, but I'd highly suggest you check it out first if you can. I made a big mistake once when I interviewed and toured a facility which for all practice purposes looked great. What I didn't know was that the food was inedible, my father's chart was lost, his coumadin wasn't administered and he was close to a level of hemorrhaging when I pulled him out and took him elsewhere.
Do you have any friends who can help you tour the facility? You could quickly locate a local or state ombudsperson and ask if the facility has a good or bad reputation.
Google "ombudsman" for your county, then your state, or even ask one of the hospital staff (who contacted your husband) for the number. Make sure it's stated that it's to check out a rehab center so the hospital doesn't think you're getting ready to complain about them and start circling the wagons.
Linda offers good insight on a hospitalist vs a PCP. Because we'd been through that scenario before, and once it was a terrible situation, I found a PCP who also takes point as attending physician, so the last 2 visits were managed by the PCP instead of hospitalists.
I think various hospitals are in different stages of adapting to hospitalists. My first experience with them was in Ann Arbor, with a well respected teaching hospital. It was years before local hospitals moved to use of hospitalists. Some are good; one stunk - he and his residents were so bad that I actually had to tell one that the questions she was asking were none of her business, and to leave Dad's room immediately. (She was asking how he felt about death, if he believed in a god, and more, and wouldn't he agree that he'd "had a good life" and shouldn't be resuscitated if he crashed - she was way, way out of line.)
Just a heads up...sign nothing that makes you responsible for payment.
Medicare pays 100% for 20 days, 21st to 100th day 50%. If she has a suppliment they may pay some of it but not all. If MIL has no money other than SS and a pension then tell admitting at rehab Mil may need to file for Medicaid if she is in longer than 20 days.