Hello, Folks.
It’s been a long, long time since I posted here but I am wondering if any of you have any insight. My mom, 84 with a history of COPD, hypertension and severe scoliosis (which causes restrictive lung disease on top of the COPD) broke her hip at the end of December. She was hospitalized, surgery was performed and nada brief stay at the hospital. She is now at a rehabilitation center nearby. She has been there for about three weeks and they are planning to discharge her on Saturday. The thing is we are very concerned that she cannot take care of herself. The rehab has been a disappointment. Sub quality care, confusing communication with us, etc. We had a meeting last week with her “team” and they claimed that she was pretty much on target and would be okay to go home with follow up care. But this week, my mom told me that her PT told her that she is concerned that my mom is not safe on her own and I got a call from one of the therapists saying the same. My mom has some issues with memory and following directions that require a sequence. This is interfering with her learning how to use some of the adaptive equipment. Along with all of that she has become completely dependent on oxygen and will have to go home with a portable tank along with her walker.
My questions are:
Can the rehab discharge her if she is not ready?
What options do we have other than a nursing home?
What is the responsibility of the facility to have another meeting with us. They are refusing, saying that we already had one.
Just make absolutely sure that all discharge orders are done before she leaves. For example…if she needs in home PT, or other home health support, get that arranged before she leaves the rehab place. It’s better to have all the supports in place than to not.
Re: the need for PT…I don’t know your mom’s particular case, but can she continue PT at home? Has she had OT to make sure she can handle activities of daily living (like dressing and cooking)?
Other options…can she get home health support…we had that for my parent…three times a week. It was wonderful helped with cooking, personal care, etc.
Also had in home PT for a while…then PT at a clinic.
Is your mother is an inpatient rehab center or a subacute rehab center in a nursing home ? To answer your question , can they discharge her if she’s not ready ? Yes, they can and will if she no longer meets level of care for the rehab facility or is no longer making progress because of her memory deficits. It sounds like she needs additional rehabilitation in a subacute facility in a skilled nursing facility. Ask the Social Worker to send referrals to subacute facilities in your area. This does not mean that she will stay at the nursing home after her rehab is done. It does sound like she will need assistance or supervision even after her hip heals especially if she remains oxygen dependent. That may mean someone living with her, assisted living or skilled nursing. It is too soon to say . Good luck.
Have you been able to sit in on an interdisciplinary care team meeting at the rehab center with the social worker,PT, etc? Has the possibility of home health come up?
If OP’s mother is having the cognitive deficits she describes , it sounds like she will need more supervision than can be provided by HH coming in several days a week. What about when she has to get up to toilet in the middle of the night or when she needs to prepare something to eat, especially now that she has oxygen to transport ?. It’s not just about her being able to walk with a walker. Depending on the the type of surgery OPs mother has had, she may be on hip precautions which place her at risk for hip dislocation if she can’t remember them. As an Occupational Therapist who has worked in acute rehab, subacute rehab in a nursing facility, home health and currently works in an ALF , it sounds like an extended rehab stay in a skilled nursing facility would be the most beneficial if it can be arranged before she is transitioned home unless there is someone to supervise her IMO based on the OPs presentation of her deficits.
Unfortunately this happens all the time. Sometimes it is due to insurance or Medicare limits. Sometimes it is because the client/family definition of safe at home does not match clinical definitions (eg being able to pour yourself a dish of cereal equals being able to take care of food needs). Sometimes the client fails to progress and thus flunks out of rehab or reaches as high a level as the therapist thinks is possible.
Those who can afford it or qualify for waivers can get some in home health aides or follow up therapy. Those who can’t are in an almost impossible situation
Try making a call to the facility social worker or calling your local office of the aging.
If your mother is sent home, Medicare will pay for PT in the home while she is considered homebound; when she is no longer meets homebound criteria, Medicare will pay for outpatient PT.
I wish my mother had been allowed to stay in the rehab/nursing home area of her CCRC beyond the first 4 weeks after being discharged from the hospital after she broke her hip in 2011. The rehab unit team sent her back to her IL apartment utterly helpless, and I had to hire a 24/7 live in caregiver at great expense to my mother, for 4 months. VNA provided PT (I am a PT and supplemented this), and eventually she was treated as an outpatient at the same CCRC’s PT department where she was being treated initially.
You mother probably had a hip replacement. Unfortunately my mother had to get a Richards screw and plate due to the location of her fracture. This greatly slowed her progress and resulted in a huge expenditure-- full time caregiver for 4 months.
It’s obvious to me that your mom needs a health care aide at home with her or needs to be in a nursing/rehab facility. My mom( 87) just spent 3 weeks in the hospital and on the rehab floor of hospital for 5 broken ribs/punctured lung she suffered in a fall. She has an aid 6 hours a day (10-4) and I am here from up north for at least another month. Aides cost around $15/hour. We hired a private aide to stay with my mom from 9p-9am while she was in the hospital. The aide she has now is through her long term health ins but if she didn’t have that we would have had to hire a private aid - and my mom has no other issues at all and is sharp as a tack. She gets PT in home 3xweek and the nurse comes twice a week. Very lucky my parents took out this insurance years ago.
When MIL broke her hip, one of us, usually me, accompanied her to every single PT session to make sure the assorted PTs were documenting any and all improvements to maximize Medicare coverage. Once she plateaued, they offered their SNF at $8600 monthly and also suggested Board and Care homes, like a day care for adults, but you live there, in a house/home, with a max of 6 adults being cared for and 24/7 care, we saw prices from $1800-$5000 monthly depending how fancy the house and whether a room was shared.
That is where we picked.
She still thinks she is going home, but the house has been totally renovated and rented, the pair were too old and fragile to handle their home of 50 years, FIL had been successfully hiding many deficits.
It’s rough, really rough, DH & I are exhausted. It would be rough even if FIL was not a jerk, but he makes it so much worse with his attitudes and actions.
Carolinamom, yes. It sounds like you have hit the nail on the head. Thank you to everyone for your help. My concern is that she is NOT safe at home alone even for a short time unless she is just sitting watching TV. She cannot toilet herself, uses diapers in the rehab and they don’t seem to be working particularly hard to help her regain her independence that way. I will look into subacute rehab.
She is on hip precautions and seems to need a lot of safety prompts from the therapists working with her. That is part of the problem and I do think the reason they want to discharge her is because she has plateaued in her progress. I am annoyed at the lack of communication and mixed messages that we are receiving and at the refusal of the social worker to call a meeting. We have until Saturday to figure this out.
All of us, her children, work full time. Three of us live in houses that are unsuitable for an elderly, disabled person and the fourth one is reluctant to take her (even though she has offered many times in the past). Sad and frustrated.
I did fall off the planet. No particular reason, just so busy, I guess! I volunteered for too many committees at work and became overwhelmed. Thanks for missing me!
It sounds like wherever your mom lives, she will need care and supervision. If you are all working full time, it does not sound like anyone will be available for this, even if she lives at someone’s home.
The transition and discharge social workers are supposed to be able to help evaluate needs and available community resources. These workers need to be tapped NOW to figure out an action plan for a Saturday discharge.
Thing is, we had a meeting over a week ago with the SW and her team. At that point my mom was nowhere close to being ready for discharge but they were planning it anyway, assuming that she would make progress before the time came. Now it is four days away and she isn’t where we would like her it terms of self care. she cannot dress or toilet herself.
My sister called the SW today to set up another meeting and she is refusing!
I totally understand your frustration . If it’s any consolation, I’m sure that your therapists are frustrated as well. It does not make us feel good about our jobs when we are forced to send our patients home when they are not ready. Rehab has changed drastically since I began my career 30 years ago. Unfortunately the push is to provide the therapy in the most cost effective environment , and that is not in a hospital. It is also hard for family members to know what option is best for their family member. Many times families hear nursing home and automatically reject that setting for rehab because "
they promised Mom is never send her to the nursing home" These are hard decisions to make. I’ll leave you with this to think about. Typically as we age , we lose our level of independence , not become more independent so it’s important to plan accordingly. You have an acute problem to deal with right now, but please start having some conversations with your family to discuss future plans. Feel free to PM if you have any other questions.