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?

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.

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.

"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.

Talk to an elder care lawyer in your area. Do not agree to take her home. I would doubt that they can discharge her to her own care on the street. They have social workers whose job it is to find a placement. However, they are swamped and try and make the problem yours. It is their responsibility to transition her to a safe setting. If you can't or won't care for her, express that directly. Do not shilly shally to avoid stating it. It only confuses things. Also, do not make assumptions about what she can or cannot access in resources. It is a confusing can of worms, even to the experts. Talk to an elder care lawyer. Contact your local senior care county agency, or state. Do not take her home unless you intend to care for her!

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.

Talk to the discharge nurse at the rehab facility; they can recommend a few home health places. Most will charge a min. 2 hours; but will do everything from bathroom help/dressing/shopping etc. In my experience, they will take most insurance for some of the cost but won't cover everything; but it is the best place to start. 'A Place for Mom' can be a great resource and starting point in finding the care you need as well.
Everyone should qualify for Medicaid through Social Security. The threshold is less than $14,000 in 2022 - are you sure she doesn't qualify?
Please call/look them up online to determine what can be covered.
It may be time to start looking at assisted living facilities in your area. They run from simple to extravagant; but you and your husband should scout out the ones in your area. She needs more care than you can provide. Good luck!

Find Home Health Care for her until she can be by herself. Help her pay for this if you need to. Insurance plans are not going to pay for Home care or for placement in a facility.

While still in the rehab hospital/facility her safety and recovery is their responsibility when you use terms like ‘unsafe discharge’ they know you know it’s their responsibility but they will try to get you to take that on. Be very clear that you can’t see her daily or take care of anything even if this is not totally true. You may be more than willing to make her dinners and take her to appointments, find a neighbor who will check in on her and help her bathe for instance but don’t agree to it or even think about saying “we can’t do that” even for a short time. If indeed your MIL is not ready to be on her own or return to the living arrangements she had prior to this medical episode they have to find the best situation that provides what she needs and can afford. This doesn’t mean your DH and his mother can’t be a part of the process with a say although they may make it appear that way but they need to be very clear about what she needs and what she can absolutely do for herself. This means having a talk with her about why you aren’t stepping up and why she needs to not say she can do things on her own that she’s boarder line on. Yes she may be able to shower herself but does she feel safe alone in the house doing that? She can fix things in the kitchen but does
she have the energy to shop for and prepare 3 meals a day, every day? This does not mean you can’t or won’t help support her it’s just that to get the support she actually needs now you have to be clear about what help you can’t sustain a month from now.

They should be having a regular meeting with her care team in rehab that includes your MIL and her family (you and DH for instance) and if they aren’t ask for one. This is where you can ask all the questions about what happened to the heart transplant (they may say you need to speak with cardiologist but they should have a good idea) what to expect for her recovery, what she should and shouldn’t do etc. and it’s where each representative that works with her at rehab (PT, OT, nursing, discharge coordinator…) will go over her accomplishments and what they are working on. She may be nearing the end of her Medicare coverage which is why they need to release her but that doesn’t mean they plan to release her home. These are all questions you, your DH and MIL should be asking and getting answers for. Don’t be shy and don’t let the rehab dictate everything! Good for you watching out for her, she is very lucky to have you both.

A social worker at the facility should be discussing options with you. They can also help you navigate the financial considerations.

I would definitely at least hire a CNA to check in on her throughout the day to make sure things are going smoothly and help her transition back home. Going from 24/seven nursing care to being responsible for yourself when you’re elderly, can be overwhelming.

OP hasn't been back in a week, but to be clear, MIL cannot be discharged home if there is not care in place, and as OP said, she and husband work full time and cannot be there. Hopefully OP will come back and update us as to what happened.

if she is on Medicare, I believe you can challenge the discharge and they have to hold her until she can care for herself or has someone who will care for her. Usually the social workers or case manager at the facility is responsible for identifying with you how patient will be cared for at home.

Call a home care agency to see how much it will cost (out of pocket if not on Medicaid). This is usually $22-27 an hour because they take out takes and have to have workers comp insurance for their employees as well as general liability insurance. Another option is to try www.care.com and you can hire someone directly and decide how much you will pay for them. Call your church to see if they have a ministry that checks on people. Worse case is to get ADP or other video monitoring (Xfinity) so you can see she is okay throughout the day - think of a nanny cam.
Good luck!

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.

I am coming late to this. Is 63 the correct age for MIL? If so then she does not have Medicare yet.

Her health insurance has nothing to do with finding a facility. They usually do not pay for longterm care. If she has a small income, she should qualify for Medicaid. In my state the income cap is not a little more than $2300.

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.

Get connected with a local social worker to discuss her options. The basic options are to hire in-home caregivers or an assisted living facility. Much will depend on her finances. You may have to put several things in place to get this to work. Make sure that all of her paperwork is in order. She needs to set up powers of attorney for medical and financial matters, a living will with her advance medical directives and a will if she has assets. The social worker may know of resources to help your mother with these legal papers, if needed. All the best to you, your mother and husband.

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.

Be sure that your husband is speaking with a qualified Case Manager to assist with finding the best choices for you all to consider ( usually a Social Worker but may be other disciplines depending on the facility ) . Also be sure that your husband has had the conversation with the MIL physician that includes choices for care that may include hospice care ; ask pertinent questions about your " not understanding the sudden change from needing a transplant to not "; is the MIL in " end stage heart failure" ? Prognosis? Physician plan of care from this point? Would hospice care be an option? Your husband as the PCG ( primary caregiver) has the right to bring up "hospice care" for more information and/or to contact a hospice to learn more about this service and, if it is applicable in this situation. Hospice is about living with quality of life not about dying. This is an option that often does not get referred soon enough in many instances ; and it may provide some options and care for both your MIL and the family support that will make a difference.

we have been battling with SNF for my MIL they sent her home & she wasn’t even able to get out of the wheelchair, let alone take care of herself we filed a appeal & they denied it even though my MIL sat in her own feces for 12 hours (we weren’t in town & didn’t find out until the next morning) so we called 911 & sent her back to the hospital. We have been battling with all of them since April. We finally put her into a home but she is too much for them & we are paying $3600 a month & they don’t even take her to dialysis or appointments.
The one thing I have learned is if they want her out of the facility they will achieve it, insurance usually pays for 2 weeks & if they aren’t trying to help themselves they will kick them to the curb. My MIL just now finally started to try to do better & insurance was trying to send her home & the facility actually filed the appeal for her.
Good Luck