My MIL is getting discharged from a rehab hospital, but she can't care for herself. Any advice?

You tell the case manager and SW at the facility that discharge home would be not possible and unsafe as there would be no one there. Don't think you have to pay in home for caregivers out of your own pocket either. Don't do that.

She can qualify for LTC Medicaid or nursing home if she medically needs it. She needs to spend down her assets (or private pay first) then she gets put on LTC Medicaid. See a elder attorney if desired or talk to a Medicaid specialist.

Start by having your husband tell the facility that she CANNOT be discharged home as there is no one to care for her. It's called an "unsafe discharge". Do NOT pick her up.

If they send her home to her place in a cab, call 911 and send her back to the hospital.

Is your husband poa for finances and health?

Has HE talked to the doctor?

Has he consulted an eldercare attorney about Medicaid?

A person who needs an organ transplant has to meet certain strict criteria first; and if they do, then they're put onto a long list to wait. My DH needed a liver and waited well over a year (after extensive testing and meeting the aforementioned criteria first) before he was called down to Phoenix to the Mayo Clinic to wait again for a donor to pass away to receive the organ, IF it was healthy and viable. A heart transplant works the same way. You'd need to speak to your MILs doctors to see what happened in that process to disqualify her from getting on the list in the first place. Age could play a factor, but so could tons of other things.

Medicare doesn't pay for long term care in a nursing home, only for rehab for 20 days or up to 100 days if the person qualifies for that length of time. Having a 'small monthly income pension' should not disqualify your MIL from getting Medicaid; please make an appointment with a Certified Elder Care attorney to discuss that matter in greater detail, that is your best bet.

Telling the discharge team that your MIL is an 'unsafe discharge' is also a good idea, so she's not released back home with nobody to care for her there. Refuse to accept her back home, basically.

Wishing you the best of luck with a tough situation. I hope it all works out.

When is the rehab facility discharging her? What was her living situation pre-hospitalization?

DO NOT let your H bring her to your home even temporarily. Do NOT accept the Discharge Planner's promises to "find help." If H brings her home, she is no longer the rehab facility's responsibility. Did mil tell them that someone would be helping her at home?

Keep us updated.

"My husband is finding a hard time finding a facility that will take Humana."

What kind of facilities is he looking at?

When you say "Humana", do you mean Long Term Care insurance? Medicare and private insurance do not pay for Assisted Living or NursingvHomes.
Depending onyour state, Medicaid will pay for NH, maybe for Assisted Living.

It sounds like he needs to have a long talk with the Social Worker at the rehab where she is now to more clearly understand her needs, her resources and the timeline.

Tell the rehab center they cannot discharge her until she has a safe environment to transfer to. Refuse to sign release forms. Refuse to take her to your home. The minute she’s released, rehab is off the hook and it’s all on you.

Contact social services at once. Tell them that a discharge without proper discharge plan is an "unsafe discharge " and that they will be reported to JCAHO if it is done, or whatever regulatory body directs them.
If your MIL cannot be alone this is late in the day to try to start discharge planning, but it is what it is. Who is the POA? Is there one? If not, it is time to take care of that as well.
If MIL cannot care for herself I would warn all NOT to let her come home with you helping and not to take her, above all, into your own home. You will never get her out of it, IMHO. Start with the fact there is no one to care for her in home, she cannot afford in home care (if she cannot), and she cannot come into the homes of family. Then begin for placement planning, assisted living, board and care, nursing home, whatever her needs are. Your Mom's assets, all of them including pension, will likely now automatically go to her caregiving facility, with medicaid picking up the slack when all assets are accounted for and being turned over, and are not enough to give her care. You may need a medicare planner to help negotiate all of this. Ask the Social Worker how to go about finding one.
I am sorry this is coming on the end of all this. I don't know her age, but transplant for heart and lungs is very difficult process with the need for someone with MIL 24/7 or at least the length of a year, so that likely is not in the future and I doubt it ever was.
You need advanced directives worked out with MIL as well, if she doesn't already have them, and you need to know her realistic goals and ideas should her condition progress and cause further debility.
My best to you. I wish you all good luck and good care. I am very surprised you have not already been contacted by Social Services.

With no one to care for MIL, it is an unsafe discharge from the hospital. Nursing home is the only option, regardless of income. Once assets are spent down, Medicaid will take over. Talk with an elder lawyer and social worker.

Keep screaming UNSAFE DISCHARGE - those are the magic words. They will try anything and everything. They will promise help that won’t materialize. Do not pick her her up. Do not sign any paperwork accepting her care.

Push for admittance to a facility for further care. She cannot live alone.

OSV404: You must state that this would be an UNSAFE DISCHARGE to the home. I am unsure why your MIL is not on a list for a heart transplant; maybe you'll need to determine the reasoning behind this. Perhaps you should also retain an elder law attorney.