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She's on home oxygen, noncompliant with meds and can't take more than 2 steps. Shes been there for 60 days and needs more skilled care. She's on Medicare. How can I convince them she needs to stay longer?

Patty, does she live alone?
Are they saying that she is okay to go home alone with home health?
Do NOT pick her up. Do not sign that you agree to discharge. Let her sign for herself.

When they send her home, call Adult Protective Services and ask that they conduct a wellness check.
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Pattyreddp Mar 4, 2019
No, I cant pick her up. They will provide transportation for her and charge her $50. Im still at a loss for words but time will tell. She will be calling 911 within a week or 2, then back to the hospital. Im really done with this horrific system. Very sad!
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Medicare only pays for so many days (I believe it is 100 days maximum). it's rehab--not permanent placement. Further, they have to chart some kind of improvement in order to stay in rehab. If she does not cooperate with physical therapists they will chart "refused" and it's back home. It sounds like she needs permanent nursing home placement. Contact a social worker to get her on Medicaid; however, another option is hospice. Medicare pays for hospice.
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ImageIMP Mar 6, 2019
I previously explained this process in detail... Yes, Medicare (Part A, probably) will cover up to 100 days in rehab/skilled nursing following a hospital stay. (UP TO 20 days all-paid and UP TO and additional 80 days, with a co-payment) The facility, though, decides at which point Medicare will deem the patient isn't making sufficient rehab progress (and not pay after that), and the facility schedules the discharge date. (They "guesstimate" this date to be before Medicare stops paying, but that's what it is - a calculation on their part.) They should HAVE to provide a Medicare-rights sheet at the time of discharge notification. This will have the process, and phone number, for appealing the nursing home's discharge decision and date. You (your step-Mom or responsible - POW - person) has the right to appeal the discharge with Medicare. They will have medical and rehab records reviewed by medical personnel, and decide - within 48 hours - whether YOUR appeal will be upheld, and the patient allowed to stay for an additional period, or whether the discharge is proper as scheduled. This process can (and probably will) be repeated a number of times, and the same options are available each time. (I appealed my Mom's discharge 3 times, was upheld, and she ended up staying for 96 out of the 100 days! - apparently almost a record, because the facility was really shocked!) When she is to be discharged, you do not have to take her in - cover her costs - even make arrangements for placement. You can "warn" them that if they place her in an unsafe situation (for instance send her home if that isn't safe and appropriate) you will scream bloody murder to Senior Protective Services. Keep a journal/record of everyone you talk to, what was said or decided, dates/times/etc. - and keep a record of any valid requests you make that are ignored, and any care meetings, arrangements, promises, etc. they make that they don't follow through on! Keep a record of everything!
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Pat, if they "threaten" that the state will take over her care, say "yes thank you".

You can't help someone who doesnt want to be helped.
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I agree talk to the doctor in charge of her care. But realize that Medicare determines whether she stays or not. If Mom is making no progress, then Medicare will not pay so she will be discharged. They have done what they could.

She has a Pulmonary doctor, right. Call him and tell him she is being discharged. Drs.in rehab are not Specialists. In the meantime, you should make arrangements for someone to stay with Mom in her home or yours until you can make other arrangements.

The only other option you have, is to file for Medicaid and get her in LTC if she can't afford private care.
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ImageIMP Mar 6, 2019
Actually, her option(s) actually include distancing herself and simply requiring that the patient services finds an acceptable placement... She doesn't have to assume responsibility for move/placement if she's unable (or unwilling). The authorities simply can't place Mom out on the street, and she isn't responsible for Mom, or her expenses/living arrangements, unless she's willing and able...
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Joan is correct...If she is on Medicare, they will not pay if she makes no progress or doesn’t cooperate during physical therapy. You should apply for LTC Nursing Home Medicaid for her as it will be very difficult to care for her at home. You will be doing most of the caregiving. See Social Worker and Medicaid office in rehab. Tell them you don’t want to give up your life to be a full time caregiver.
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kdcm1011 Mar 4, 2019
Actually, she can’t assist with any caregiving upon discharge. She herself is recovering from neck surgery.
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Speak to the administrator of the facility. That no one is contacting you or returning calls needs to be addressed. Sometimes they don't know people aren't doing their jobs unless someone tells them.

If they won't talk to you could it be that they don't have a copy of your MPOA? HIPPA laws are applied to every person unless they verify you have the authority to get info. If you aren't authorized they won't speak to you.

Call the ombudsman and have them help you, they might direct you to resources or intervene to get a safe discharge in place. I had to stand my ground because the rehab was pushing for discharge and my dad had no safe place to go. It was awful but stay strong and keep repeating that she doesn't have care and needs a safe discharge plan. My dad was telling everyone that he had a place, my house, and I was screaming no he doesn't, could this be what is happening in your situation? You could have your doctor write an excuse letter stating you are unable to care for her.

I hope you recover quickly and well from your surgery. Sheesh, this situation is the last thing you need. Be strong and don't let them bully you or just dump her out.
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Pattyreddp Mar 1, 2019
Thank you for your wonderful advice. I have a meeting at 2 today. Hopefully I will get someone to listen.
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Go to the business office and get an application for Medicaid Long Term Care today. If she owns her home, check off the box that says that she plans to return home. Apply for Medicaid if you think she has low enough income and assets to qualify. It is my understanding that once she applies for long term care, they can't discharge her unless they feel she demonstrates all the daily living skills necessary for living independently. If there is a move to discharge, appeal it. If they deny the appeal, appeal that. Also, at your meeting, request a home assessment. This is done while she is still a patient at the rehab facility. She is driven by you or a handicap van to her home, and the physical therapist follows in his/her own car. They observe mom enter the home and maneuver about the house. This observation will inform the professional what the patient will need to return home (ie. grab bars, bed rail, room for walkers, hospital bed, ramps, etc) They can assess how competent she is while ambulating. This process proved very helpful for my dad on two different occasions. A good physical therapist will recognize great interventions and also inherent risks. I suggest you record this on your phone for your reference. If at some point she is discharged, apply her immediately for whatever Community In-Home Medicaid program your state has. Massachusetts has something called Frail Elder Waiver. Programs like this can provide up to 18-20 hours a week of in-home help. Once she is on Medicaid and a Frail Elder Waiver type program; it can take quite some time for them to process the application. My mom was able to benefit from frail elder waiver which allowed her an automated locked med dispenser, life-line, and help 5 days a week divided between mornings and supper times and qualified her for adult day care although she never partook of that. This allowed her to live "independently" for over two more years. Yes, I did help her too, but it was doable. When she landed in rehab after breaking her hip and wasn't participating enough for Medicare to say she could stay, the Frail Elder Waiver assessment nurse clearly recognized that mom would need too much care to return home and okayed her for up to three more months in the facility. (As an aside, I would like to see a Medicare appeals person break their hip and only address the pain with Tylenol and perform the level of physical therapy they expect. It would be very difficult at even half the age of my mom!) For some individuals the extended stay can allow for them to improve enough at a kinder pace in order to go home. If not, a long-term care application is completed. Your mom might require hospice. This can be provided in the nursing home. An in-take nurse will determine if she qualifies for hospice. I was in your shoes back in 2014. I knew nothing about anything. Hopefully, you will find a kind business office person, or social worker who will show the way. My guardian angel for applying mom and dad to Medicaid was a hospital administrator where my dad had been a patient in the recent past. The business office at the rehab/nursing home helped with the Long-Term Care applications for first my dad and then my mom when the need arose. The community elder outreach person also was helpful. Keep asking questions, advocate, and persist. Good luck with everything.
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Having worked in LTC, I find this quite bizarre. Once it becomes apparent that the resident is nearing the end of their stay, P.T does a home eval. If the resident is safe to go home then measures are taken to ensure DME equipment, etc., is ordered and set up. If the resident is not safe to go home, and appears to need long term care, then a care plan meeting is set up to help the family with the arrangements, and the resident stays in the rehab wing until a bed becomes available. Furthermore, if they cannot stay at the current facility, then they and the family make arrangements for another LTC facility transfer. A resident CANNOT be discharged to an unsafe environment. I would contact whomever governs LTC facilities in your state....
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ImageIMP Mar 6, 2019
Yup - and, if the "family" is unable or unwilling to participate in the arrangements, the facility and/or Sr Svcs. has to find a safe solution...
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You have of the option of refusing to take her. While it is correct she cannot stay indefinitely at a rehab, the discharge planner and social worker should work with you to find nursing home placement. Is it possible to private pay the the rehab until you have nursing home placement?
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Pattyreddp Feb 28, 2019
No, shes on medicare and broke. She is at a state run “rehab” after being admitted to the hospital for shortness of breath. They are a medicaid nursing home and I was hoping they would keep her. Im not sure how they can send her home in 6 days without speaking to any family. She is very unsafe to be alone. She falls, forgets when she last took meds, abuses her meds, etc. former alcoholic, now abuses pills. Im just at a loss for words. Its an accident waiting to happen. She has no family and Im in no shape physically to care for her.
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She needs a neuropsych evaluation or may just a geriatric psych evaluation to confirm that she is unsafe at home. They need a diagnosis of something like alcoholic encephalopathy or dementia to work with to confirm she is unable to care for herself due to cognitive dysfunction. She needs to have competency determined and have a POA or guardian established to make decisions for her. otherwise, she could just be allowed to make her own decision, call 911 again and end up in hospital again. If rehab won't help coordinate this, they they are stuck with a plan for her and may just decide she is compenent.

Note to all, when you have a LO in hospital or rehab, enjoy the break but start working on discharge plan immediately. Your house does not and should not be the discharge goal, but don't expect the hospital to do the heavy lifting for you. If you don't think LO is competent, ask for an evaluation while in the hospital so they can confirm that. Otherwise, if person is felt by hospital/rehab staff to be able to make their own decisions, they can just send them back to their prior living arrangements. While it is usually obvious to family that person cannot life alone safely, it may not be obvious to caregivers.
If family member is still at home, and doing fine, then read Being Mortal and then have the hard discussion with them, get the POA done and don't be an ostrich or allow them to be.
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