The hospital should have a social worker, the rehab facility may as well. These people know the system and can help with resources. There’s a system for appealing a discharge that stops the process and gets more people involved in the decision if you feel he is not ready to move to a lower level of care.
I have a dear friend with some chronic health issues. The problems she has encountered receiving care border on absurd. I wouldn’t believe it if it hadn’t happened to her so many times. I hope your dad is quickly able to get the care he needs to recover well and resume his life.
My sister didn’t find the hospital social worker to be very helpful, unfortunately. Yes, the system seems to be quite inadequate.
Rehab places sometimes have excellent, more pro-active discharge coordinators. Paired with your family knowledge and perhaps advocate/geriatric care manager, it could be useful.
Re: the medi-gap policies paying after the first 21 days: in my experience, the feature of extended coverage (was it to 90 or 100 days?) for skilled nursing rehab was a very important way to cover all bases and access optimal care. Can make a huge difference to a senior’s recovery, as well as allow time to put discharge plans or a move to a higher level of care in place. A critical variable in selecting Medi-gap plans and worth checking in advance of need.
All the best, @MaineLonghorn .
With regard to your dad’s leg infection/wound, now that he is back in a medical type facility, maybe he could be given IV antibiotics to deal with it.
We are planning a party for MIL’s 95th birthday and I have to do it at her house because the last time we tried to put her in the car, it took H and 3 out of my 4 sons (who are all in their 20’s) to lift and place her in and out of the car. The only reason they even succeeded is that H and one son have basic EMT training and had a slight clue as to how to do it.
Yes, even my fairly small mother (5’7 but not a lot of weight on her) , became dead weight when she was compromised and needed any physical help. So glad your dad will be getting more rehab care . The folks on the Parents Caring for thread may be the best support and guidance for you. They are currently in the trenches with you. It is very difficult. All the best.
Good news. So hard long distance for you and so much on your plate. Hang in there. Lots of prayers from your cc gang.
Glad to read about the progress. So sorry it has been so tough.
Yay, I talked to Dad just now and he’s on board with hiring the patient advocate. He said he’s not sure how much we’ll need her, but it’s fine to have her available. My sister and I are very relieved - WE know how much we need her!
I’m so sorry to read the initial post and sure hope things are on the upswing now.
@VaBluebird, yes he sounds much better today. The rehab place seems to do a good job of monitoring him and getting him PT. This time, we’ll try to make sure he stays in long enough!
Also another consult you should ask for is a wound care nurse to assist with the care of the bedsores.
Ugh, Dad was just transferred to ICU. Respiratory issues, losing some blood, and retaining fluid. I hope he’s alert enough to sign the release form for the patient advocate.
Oh no @MaineLonghorn! I’ll be keeping your dad in my prayers!
Does your dad have a health care power of attorney? If so, that person can sign the release for the patient advocate. If not, next of kin should be able to do it as well.
@momofsenior1, oh, gosh, thanks for mentioning that! My sister has medical power of attorney! 
This is why I love CC. You guys are the best.
It’s hard in times of crisis to keep track of everything. Your sister will have no problem signing for your dad.
Sending cyber hugs!
I went down in October to help my parents start getting organized for an eventual move, and during that process we talked to a company that manages care for elders. They suggested completing paperwork for medical power of attorney and power of attorney, and my parents agreed to give my sister MPOA and me POA, just in case. Thank goodness! We had no idea we would need it so soon.
I’m feeling discouraged that our health care system is so broken that families have to HIRE HELP to navigate it. It really is unconscionable. We are just fortunate that Dad can afford this, because my sister and I can’t - we each have multiple kids in college.
IMO, everyone should have a MPOA and POA, at any age. You just never know when you are going to need it. We did them with our first wills when we were in our mid 20s and have updated as we’ve moved states.
Our health care system really is broken on so many levels. Communication between specialists is the worst, let alone to families. It makes a very emotional time unnecessarily more stressful.
Sorry to hear your dad was back at ICU, but the only good that might come out of that is getting discharged to another acute rehab and then making sure he stays as long as he needs to. My mom just went through this, we managed to have her stay for about 90 of the possible 100 Medicare-covered days, and would have paid for more if we’d had to, because she needed the time. We protested proposed releases several times and won. Read the Medicare rules for rehab eligibility, and be prepared to meet bureaucratic jargon with bureaucratic jargon.
The hospital and rehab will see your dad at his worst and weakest, and are likely to have low expectations for his recovery prospects. You and your sister and any advocate you hire need to keep up the drumbeat that he has a high ceiling for recovery and demand that his caregivers look at him that way and help him reach it. They won’t believe you, they’ve seen delusional family members before, but keep it up. That was the most frustrating thing for my mom, that the care team though she was on the tail end of a long decline, not that she had suffered an acute setback from which she could recover.
Something I learned once. The bleep insurance companies allow a certain number of days at a certain level of care. If you can/want to pay for it yourself … you need to tell the provider that. My MIL was kicked out of a rehab facility because she timed out of her allotted days. She was sent home totally unready to be home. My FIL was more than ready to PAY but he needed to know that he could.
Hi MLH, it’s scary when such a vibrant person suddenly becomes ill. It sounds like you and your sister are a good team and I hope for a speedy recovery. I’m guessing they are assessing for sepsis from the leg ulcer (or other sire).
What educational background does the patient advocate have? That sounds like an interesting career. Only take the time to answer when you have a minute.