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Sorry in advance for typos.
My mom (74 yr) had a bad fall about 1.5 weeks ago. She broke her nose, 3 teeth and spent 3 days in the hospital.
She was moved to a rehab facility to “regain strength” and has been there a little over a week. The first 21 days are covered by medicare.
She called me concerned that she is “getting weaker” because they only spend 30 mins a day on physical therapy and keep her in bed The rest of the day .


Prior to the fall, my mom was very mobile, could drive, bathe, get dressed cook, grocery shop etc.
She lives independently with my developmentally disabled brother.
In the last 9 months there was an unexplained mental decline ( speech, and trouble managing finances, depressive symptoms etc.)
After I pushed doctors for months, she was finally assessed by a neurologist who found evidence of vascular dementia. Further testing was needed because she answered 30 out of 30 questions right in the assessment.
We were in the middle of this process when she had her accident.


I run my own business, in my 30’s and currently expecting my first child in December(2020) . All this has been placed on my shoulders very fast.
i have no idea what I’m doing and its been very hard balancing my life, my brothers future and hers.


I’m am in the midst of trying to place my brother in a group home (different story) and figuring out what My mom needs without taking her independence away.
Then this fall happened escalating the situation .


I’m afraid to take her out if she needs more help than I can give but don’t want her to get worse with the lack of mobility. She also says she can bathe, go to the bathroom and get dressed by herself (using a walker) but they restrict people due to protocol.


What are Medicare options to continue treatment for home rehabilitation and home nursing? Who at the facility do I have to call and how do I make this decision?




I ran out of space.   

When you address the issues of concern, ask for the reasons, & what can be done to address these while your mother is in rehab.

I learned that the more fragile the patient is, and the more the staff is challenged with all the patients, are key factors in allowing a patient to move around on his/her own.    Liability is also a major concern.   That might be why they're keeping your mother more or less bedbound.   They may be staff short b/c of the pandemic, and they're trying to mitigate liability if she were to fall.

Your question might be something like:  "given her fragility and limitations, HOW can we (i.e., both you and them) work toward restoring her ability to walk independently, etc.?"

Oh, and raise the issue of her teeth, i.e., whether or not and at what level (dentist, endodontist, orthodontist, etc.) she needs dental work to continue eating easily.


ETA:   I didn't address the issue of home caregiving vs. a facility; I thought the issue of getting the best care now was more important, to prepare for whatever the next step may be.  That's not to denigrate anyone else's answer; I just have a limited frame of mind, especially on hot days!
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This is kind of a summary of others' responses, with a few experiences of my own added in.

My experience has been that a care conference is typically scheduled for the second week or so, sometimes another just before discharge.   With the pandemic, it's hard to have an in-person conference, but businesses and schools have adapted to distance communication and I see no reason why rehabs can't.

All they need to do is get everyone in a room, conference call you in, and discuss what's on the agenda (which should include why only 1/2 hour of PT is the norm).   I do agree that I would verify this first; it might be hard for your mother to make time assessments in a new and uncertain environment.

One thing I learned from my sister was the issue of placement in a live meeting.   The staff typically positions itself around the caregivers, so the latter can be observed from every angle.   That helps them catch surprises, dissatisfaction, whatever.   However, in the better rehab centers, this is more to accommodate and interact than to create a live spy network on the caregiver.

Either e-mail them or raise the questions once you've requested ( and be firm!!) a care meeting, so they know you're organized and intent on getting answers.

Ask specifically about the amount of rehab, and what's the best time to contact the therapists about how it's proceeding, and get feedback.  This lets them know you're not going to let anyone slide on the amount of PT time.   You might not be able to reach the therapists easily b/c of their schedules, but they should be aware you're following their work.

I also asked for a list of exercises they're using which my father could continue at home.   Asking them for suggestions on home adaptations (removal of rugs, installation of grab bars, etc.) helps create a bond with them and they'll hopefully be more helpful. They CAN be excellent intermediaries between facility and home care.    One facility even sent the OT and PT out to examine the house and make suggestions.

Also ask specific goals, i.e., how far is it planned that Mom will walk this week, next week, and what's the discharge goal?   These can easily be couched in the statement that you need to plan for her return, adaptations to the home, etc.  They need to know that YOU have your own home care plan, and they're the major source of defining that at the moment.

I would also, before the meeting, contact the doctor who scripted for the rehab care, discuss with her/him what goals are reasonable, and if appropriate raise these at the caregiver conference and ask how those goals can be met.    Be gentle, though; this really puts them on the spot.  You can judge from their reactions how far ahead they're planning.

Home care:  

Ask the PT/OT and/or social worker (who usually handles discharge) for recommendations on home care agencies, but do your own homework.   I contacted the Alzheimzer's Assn. and got lots of good lists, which had nothing to do with dementia.    Then research online to see learn more about the agencies, make checklists of what you need, and start contacting them.  

Hospital discharge planners have lists, but I've learned that those included sometimes have nothing to do with good care.   One planner even confirmed my statement that a certain facility had a reputation for accepting patients, but many never made it out of there.    It was known as a sort of death trap.  Yet the discharge planner kept it on the recommendation list.   The politics behind that revolting practice was never revealed.

As to who at the facility handles discharge and home care, it's typically the social worker, who hands out brochures.    It's up to you to do the background work by contacting and interviewing the agencies.    The best ones I've found actually had reps in the hospitals & met with caregivers.  

Another which was top notch had an advance planner; she visited numerous nursing homes, interviewed patients and family, and set up home care.
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You can take her out and request Therapy in home. Medicare will pay for it. Talk to her PCP to see how he can help. It will be Against Medical Advice but all you need is a doctor to sign off. Don't let them tell u her bills will not be paid by her insurances, they will be.

I too would wonder why they are keeping her bedbound. My Mom had advanced Dementia and was in a wheelchair because she was a fall risk. I swore if she ever had to go to rehab again "to get her strength back" it wasn't happening. The next time would have been Therapy at her AL. You can opt out of rehab. That is your right. They didn't ask if I wanted Mom to go, they called and said "Mom is going to rehab, which one do u want?" For a woman suffering from Dementia is was not good and it overwhelmed me. Lesson learned.
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You might have to call her doctor and let the Dr know because some rehab facilities don't follow the procedures. If it keeps up I suggest you try to have her moved to another rehab facility.
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We had the same issue last year. I called the facility every morning saying I wanted to know what time PT /OT would be there so I could be present for treatment carryover. Someone in the family was there at least 3 times daily. We were vigilant and had a schedule for us. It still wasnt great but it was improved. Eventually she returned home.

Good luck!
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Tholden627 Aug 11, 2020
I wish we could do that, but Covid is keeping us out of everything.
i’m not allowed in the building. And I can only talk to her on the phone, or see her for an outdoor patio appointment
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Have you had a care conference with the facility? That's when you get to talk to all of the therapists, the director of nursing and the social worker about mom's progress.

Call the SW at the facility tomorrow and tell her your concerns about mom spending too much time in bed, according to your mother's report.

Be aware that patients with dementia are somewhat notorious for being very inaccurate reporters of what is actually going on, so be prepared to listen to what the facility has to say.
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