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I do not know what to do to help my mother or what to tell her. Her husband has been in a rehab facility the last 15 days. He is not getting better so they are sending him home.


My mother cannot take care of him. She has a broken arm in 3 places (had surgery on it 2.5 weeks ago) plus I think she has had a stroke or something recently (she is not comprehending things very well).


I was given the advice that she needs to tell everyone UNSAFE DISCHARGE. And all she is told is that her options are for him to go home or be sent to a nursing home (she or I can not afford that).

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Yes, the only options when he is no longer eligible for rehab are to send him home or to a nursing home.
I can't imagine what other scenario you might have in mind.

If your mother can not care for him at home - DO NOT ALLOW HIM TO GO HOME!
He must be transferred to a skilled nursing facility!
A social worker may have already met with him or a family member to assess his financial ability to pay for medical care, and will prompt him to apply for Medicaid, which WILL pay for his nursing home stay.
Have him transferred now, and use his current insurance, medicare, whatever has been paying for the rehab stay, while the medicaid application is being processed. If a medicaid application is pending, most nursing homes will allow the balance due to carry for a few months, assuming they will get paid once approved.

It sounds as if your mother should not be on her own at home. Do they own their home? They could sell it and move as a couple to an assisted living property.

You don't give much detail as to your mother or her husband's condition, age, or likelihood of living independently. Remember that a nursing home placement is not a life sentence! He will be taken care of for now. And if his condition improves and your mother heals adequately, and she wishes to bring him home again, she can.
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Are you local to your Mother? If not, I would definitely travel there to help her through this issue if you say she may have some dementia. There is a poop show brewing and you won't be able to manage it from afar. Yes to the "Unsafe discharge" fact. If you are your Mom's PoA then I would go to the facility with that paperwork on you as well. Is anyone the PoA for her husband? Does he have any adult children from a prior relationship who can be looped in while you help your Mom? At the facility you need to ask to talk to a social worker about having him discharged directly to a nursing home. If he has no PoA then discuss this with the social worker so they can get him on track for a court-assigned 3rd party legal guardian. You must consider that your Mom may have a post-op issue, like a UTI or an infection or hospital "delirium" which is very common in seniors after they've been on anesthesia. Please take the time off or travel to get things under control. If you don't do it right now it will just snowball. Been there, done that. I wish you success in getting appropriate care for your LOs. Please keep coming back to this forum for any further guidance you feel you need!
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Sorry to see that rehab places have financial problems from limited insurance coverage just to get Rid of their Patients ASAP!

Get a social worker’s advice that your father is in an Unsafe Discharge condition and cannot return home. He belongs in an NH or AL. And, don’t sign the rehab discharge documents, please, as your mother is unable to care for her husband/your father.

If his funds are running out soon, apply to obtain your father Medicaid.
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Nursing home can be one that takes Medicare and/or Medicaid. Ask social worker/case manager to help with this.
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cin6004: The patient can't come home. Period.
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My mother and I were clueless when they did this with her husband. We did NOT say he was an unsafe discharge. We didn't know what to say or do. So the nursing home put him in my car and we dumped him into a bed in my mom's home. He died about a month later of liver cirrhosis due to alcoholism. We weren't allowed to know what was wrong with him because he had refused to put anybody down in HIPAA paperwork, so doctors at the hospital wouldnt discuss his condition with us. He wanted his disease to be kept secret. His last month was a mess since mom had dementia and nobody could leave work to care for him. We weren't even advised to call hospice and nobody told us he was terminal. I had heard the word "hospice" before but I didn't know what they were or what they do. The nursing home doctor was a no-show. My sister helped with his diapers sometimes. I went over to try to pick him up off the floor one of the several times he fell. A man he worked with came over to pull him back up to the head of the bed when he rolled down to the foot and mom couldn't move him. Mom spoon fed him. We just stared at him until he choked on his medication and the ambulance was called to take him to the hospital where he mercifullyMedicare.

These are some of the most important words in the Eglish language:
"Unsafe discharge. There is no one at home to take care of him."

Let the nursing home people say whatever they want to make you feel guilty. It's their job to TRY to get a family member to meet him at home and take over his care. When that doesn't work, they will start the process to have him placed.

Another lesson learned:
Do not sign up for "Medicare ADVANTAGE". There is NO advantage. Use original medicare.
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BlueHeron Mar 11, 2025
I meant to type mercifully died.
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Seek legal assistance advice - they need to be quoted from someone legal
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What this means is medicare will no longer pay. It does not mean they can force family to take him home especially if it is not safe. He by law is allowed to stay in the facility where he is at. However it is important to help mom file for medicaid asap. She also needs to understand there will be a share of cost usually a portion of his income. Don't let the facility tell you they have no longterm beds available as the bed he is in right now is in fact a long term bed. If they still refuse to work with you contact the licensing agency in your area.
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We just answered this quite completely on Feb 26.
https://www.agingcare.com/questions/what-to-do-when-other-person-at-home-can-not-take-care-of-a-person-

Here is the thing, he cannot come home now.
He has to go into care.
That care will be self pay if he has funds for it.
Mother will need (with your help) to consult attorney on how to do division of assets as he may not be returning home/able to return home.

If he has assets there will be no way to get free care.
If he doesn't he will have to go on Medicaid. But there simply is no good answer to needing care. When you need care your assets go to pay for your care. And when you have no assets there are programs to apply for aid.

You need now to work with discharge planning.
Coming home is not now an option.
Sorry. I know this is distressing. But we can't change it.
Only the Discharge Planning at the facility can change this.

THOSE ARE THE TWO OPTIONS
and in all truth there is no option because he cannot return home.
So the option now is placement and you have to work out how that can be done.
Refer back to your original question and Igloo's answers.
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You do not need to afford it. If you don’t take him home they will be forced to place him and get the ball rolling on Medicaid. This will not leave your mom homeless and penniless. That’s what Medicaid is for.
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ForWhatItsWorth Mar 14, 2025
Heaven forbid that the home they live in is in her FIL’s name, and not her mother’s! More info from the OP would sure help
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Those are the only options available for their situation. Rehab will not keep him if there is no improvement, they don't get paid. So, he goes to long term care facility, aka nursing home or home.

Every facility is required by law to post information about how to contact social services. This would be the route to get help getting him placed on Medicaid.

I am sorry to say it but, here is their crisis that forces change.

Sounds like you need to step in an advocate for both of them, do you have the POA authority to do so?

If not, you should contact the rehabilitation discharge planner and tell them that intervention is needed in this unsafe discharge and they need to contact the state to get the legal ball rolling to get these 2 people the appropriate care they need.
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