Newbie questions about 24/7 caregivers: legal questions, etc.

Parent Cafe
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<p>1 pm. The septic company had a rule that because the septic analyst needed access to the pipes in the basement, someone had to be in the house. So I and the dog were in the house from 8:30 till 12:30. Just scarfed something down to eat. DD2 has an afterschool activity, so can’t visit mother today. Feel bad because of the excellent advice that at the least I should “show my face.” But the girls have a half day tomorrow–get home at like 11:30 am, and after I feed them we will ALL go see Grandma. My mother won’t be able to yell at me if the girls are there; I will feel much better if the girls are there; my mother will feel much better if the girls are there; the girls are SO used to this, they won’t mind. DD2 brings her Kindle and DD3 brings her iPad.</p>

<p>I have a call in for my mother’s MD to call me. I had an excellent conversation early this AM with my mother’s Case Manager. A very skilled, caring woman. She had spoken in depth with my mother’s MD. My mother’s condition is called cellulitis. I just read a lot about it on the internet. It is very scary. When I talk to the MD, I will have ECmotherx2’s post in front of me:</p>

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<p>The Case Manager assured me that Medicare will pay for my mother’s current hospital stay; my mother will go back to the NH after the current hospital stay. The Case Manager said she would call the NH and find out how many days of coverage my mother has left. The hospital Case Manager spoke to the Head of Nursing at the AL and the Case Manager of the AL. After a period of time at the NH, the two AL women will attend the Care Plan meeting with the NH SW and others at the NH, and my mother and me, of course. At the Care meeting, the authorities would decide if my mother should stay at the SNF or go back to AL. When the two AL women spoke to me, they did not sound happy. They pointed out that my mother had fallen almost every day for the short week she was at AL I said that each time my mother fell (I believe each time she was going to the toilet without an aide, which at her care level, she must do–have an aide) it was because she was not attending to the rules. That it someone or a team could forcefully get it through to her that she MUST have an an aide assist her with A, B, C, D, etc., she would stop falling. She can self-propel with her wheelchair. I said it would break the family’s heart is she were not readmitted to AL, and that this current rehospitalization/stay in rehab might teach her a lesson. But both women countered, she had been told many times by many people that she cannot go to the bathroom unaccompanied, but she persisted in doing so, and fell each time. </p>

<p>If an elder falls 1, 2, 3, times trying to use the bathroom alone, why does she keep trying to go unassisted? Why can’t she learn to call for an aide? Why fall again, 4, 5, and 6?</p>

<p>We ended the call with my question: I said, if I read between the lines, it sounds like you are predicting it is much more likely that my mother be assigned to a SNF than be readmitted to AL? The Case Manager said no, no, it is much too early to say that, and we are not leaning one way or the other. Lets give her leg time to heal and give her time to get lots of PT at the NH, and hope that she has learned her lesson. </p>

<p>The hospital Case Manager told me she would call the NH and find out how many days left of Medicaid coverage my mother had left there. Also, I have to scroll above and reread LasMa’s post --LasMa, thank you for going to the trouble of doing the research–and look at the link LasMa provided. </p>

<p>Seeing a priest for free (well, giving it some thought for a second, I would certainly leave a contribution) as a "one time thing"won’t do me much good. I will ask my daughter’s excellent therapist to recommend a few therapists and see which ones are in my network. But I need to find the right time to take the step–and now my sister is coming for a week on Sat pm.</p>

<p>I will scroll back later to see if I have covered all the useful and welcome comments and questions.</p>

<p>But I must tell you, the septic analysis could not have been more disasterous. The septic tank is entirely collapsed (we knew that already) and what leaves the house has no where to go because there are two big, deeply rooted maple trees blocking the fields. When I spoke to the Director, he said there was probably a way to save the tree (actually there are two compromised trees) but the on-site analysist said the trees probably have to go, and the deep roots dug up to allow for septic fields, because although the property isn’t tiny, there is no where else to put fields. An Engineer must design a whole new system. I have a call in to him to call me asap. The Department of Health has to issue a certificate which takes time. The analyst said there was no way for him to give an estimate, but once the Engineer had visited the site, he probably could: range $10,000 - $30,000. I already knew this was the range. The company will wait to be paid at closing, but I don’t know how we’ll get the cash to take down two huge trees. We will have to continue paying the AL rent while my mother is in rehab; if I don’t find out from the hospital case manager how many days of Medicare coverage my mother has left at the NH by 3 pm, I will call the Social Worker at the NH myself and ask. Would she be the right person to ask? Actually, I think travelnut answered my question, above:</p>

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<p>LasMa:

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<p>Just called the NH and learned that my mother has 23 days left of Medicare NH coverage.
Yes LasMa, my mother has secondary future.</p>

<p>Just to be b*****, I am so sick of typing the words “my mother.” When I talk to her, of course I call her Mom. But when I talk to friends about her, or email my sister about her, I refer to her by her first name. </p>

<p>Also learned from the woman I spoke to in Admissions at the NH that my mother is expected to be discharged Saturday. Just left the Discharge Manager a voicemail asking that my mother be kept longer–that cellulitis is a serious, potentially life-thrreatening condition condition, and that I would be much more comfortable getting the “excellent care” as I put it in the hospital, than being discharged on Sat to the NH.</p>

<p>Thank you to those who suggested I call the discharge manager. I left my number and asked to be called back regarding a longer hospital stay for my mother.</p>

<p>Whew! Have to rush off and pick up DD3.</p>

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<p>Dharma, read my second post, not the one above it. I don’t think there was ever a question about Medicare covering the hospital stay. It’s more SNF days that we’re talking about.</p>

<p>I could write a book about elders and falls. I’ll pop in with some thoughts later, but the end of the book goes like this: There’s nothing you can do to change her, and trying will only frustrate both of you. Your job is to get her to a place that’s safe for her, given her current limitations which include inability and/or refusal to follow instructions. </p>

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<p>Dharma, cellulitis is fairly simple to treat–IV antibiotics, keep testing for remaining infection. When the infection is gone, there’s no need for her to be in the hospital. My dad had it several times until finally he was referred to a vascular surgeon (a misnomer–not just to cut people open!) and for his final 2 years of life, he wore the stockings every day and never got cellulitis again.</p>

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<p>Yes LasMa, I did go by your second, corrected post.</p>

<p>Very interesting what you say about how “there’s nothing you can do to change her.” If we follow this line of thinking, that means she lives in a nursing home at $15,000/mo. And I have to “unmove” her from AL.</p>

<p>Reassuring to hear, oldmom4896. The site I read went into detail and talked about how complications could cause the condition to become “life threatening.”</p>

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<p>Dharma, she’s being treated in a hospital. If it hadn’t been monitored and then treated, it could have become life-threatening.</p>

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<p>You might not like that scenario, but your liking or not liking it is irrelevant. If you can’t change her, she can’t stay in AL. It’s been clear from the start that she was iffy for the AL, and now her health is declining. So she might not be able to go back there.</p>

<p>“Unmoving” her from the AL, if it comes to that, will be a lot easier than moving her. She’s going to be discharged to the nursing home. If she has to stay at the nursing home forever, well, then she has to stay, and you just have to remove her things from her AL unit and wind things up with billing. </p>

<p>You’ll know more about the AL status in a couple of weeks. No sense even worrying about it now. Just deal with the house sale and the septic. BTW, sorry to hear that what the first septic report clearly outlined as the worst-case scenario turned out to be true. Oh well. Just schedule the work and get it done. </p>

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<p>Dharma, great job today on making all of the contacts and keeping to the most important things. So sorry to hear about the septic. I am a little concerned about the follow up care at the SNF. When your mom was ready for discharge to AL didn’t she have edema and redness in her legs? I think that you replied that the SNF was aware of this. Without knowing for sure how she was evaluated or monitored, I’m sorry to say that I think that this is something that you will have to stay on top of during her recovery. I know that you shouldn’t have to, but it is something to mention on the intake information for transfer back to SNF.</p>

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<p>Just to be clear, cellulitis is a big deal. Years ago, i took my MIL to the doctor for a small spot of what he diagnosed as cellulitis. He took a sharpie and drew a circle around the edge of it and told her, “If it goes outside this line, i want you to go to ER.” So yeah, it’s serious. </p>

<p>Skilled nursing around here runs $8-9K per month. I know it would vary by region, but $15K sounds high. I suggest you do some checking around. Or if you want to do it the easy way, talk to a senior placement specialist. </p>

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<p>Yes, it’s definitely serious but it was diagnosed and is being treated in the hospital.</p>

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<p>Yes, it is treatable. Although when my dad had it, it took more than antibiotics. They had to do surgery. It had something to do with the ankle surgery he’d had the month before; I don’t remember what and I’m not sure I understood it even at the time. My head was spinning by then. That was the third of four hospitalizations he had in the last four months of his life. :-(</p>

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<p>Cellulitis can be difficult to treat. I’m glad that Darma’s mom is in the hospital with the ability to administer IV antibiotics, wound care, labs ordered and reviewed. IV antibiotics can wreak havoc on an older person’s intestinal flora resulting in C-dif. Sadly, the chance for contracting MERSA is also high in these cases. Her mom has coronary artery disease and these infections put stress on the heart. Now that she has this history, her legs need vigilant observation and an immediate response should edema, redness, pain, warmth, etc. be found. This is my concern going forward wherever she may be discharged to.</p>

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<p>The estate sale is this weekend, right? That should net you some cash. Maybe your BIL can use his line of credit it help cover the rest.</p>

<p>The cost of SNFs is high in this area, too. It definitely costs more in the NE-- NY is high, CT is even higher. </p>

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<p>According to this, average in NY is $344/day, or about $10K per month. I do understand the danger of averages; still, it might be worth shopping around a little. </p>

<p><a href=“Nursing Home Cost”>http://www.seniorhomes.com/p/nursing-home-cost/&lt;/a&gt;&lt;/p&gt;

<p>I also need to point out that running out of money at a SNF may not pose the same eviction problem as running out of money at an AL.</p>

<p>ETA – Here’s another source which puts it at about $10K.</p>

<p><a href=“New York Skilled Nursing Home Facilities”>New York Skilled Nursing Home Facilities;

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<p>If she ends up having to transfer to a SNF permanently and subsequently runs out of money (a common occurrence), she can apply for Medicaid (the process can take 6 months so she’d apply for Medicaid while spending down.) </p>

<p>Even if it costs more, I’d want my mother at a facility close to me. You could be driving there for years to come; make it easier on yourself.</p>

1095

<p>I have just read through all the comments posted since my last post. So grateful for the loving support, and I mean the word loving.</p>

<p>DH is calling me to eat what he has prepared for dinner. Daughters have a half day tomorrow and get out at some absurd time like 10:30 am. We will go straight down to visit Grandma.</p>

<p>I tried her direct line several times but got no answer. Probably in her favorite place, the bathroom.</p>

<p>Sadly, got her nurse on the line on another call. I am pretty good with languages, but so sadly, the nurse had such a strong foreign accent I did not understood a word she said. I had to say we had a bad cell phone connection and said goodbye.</p>

<p>I have a call into the Director of Discharge; she did not return my call. I will call again tomorrow morning and ask that my mother be kept in the hospital longer than Saturday, her planned day of dismissal.</p>

<p>And my sister and her friend step into all of this Sat pm.</p>

<p>Thank you all; so grateful; must follow DDHs directive to come and eat. DW xxxx</p>

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<p>Well you certainly are experiencing a Perfect Storm: Mom in hospital, septic problem, sister visiting and estate sale all at the same time. You had better listen to your H and eat, sleep and take care of yourself.</p>

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<p>OK, so this seems to me to be trying to do someone else’s job for them. You’re not an expert on cellulitis; you had never heard of it until today, unless you read oldmom’s message yesterday. You haven’t seen or talked to your mother since she was hospitalized, so you don’t know anything about your mother’s condition. The people who are experts on cellulitis, who have seen your mother and who are treating her say that most likely she’ll be ready to be discharged on Saturday. On what basis are you challenging this decision?</p>

<p>This seems like borrowing trouble. You have so much on your plate already, with the estate sale tomorrow, the septic repair and the house sale, plus your family responsibilities. It’s wise to keep an eye on how the hospital is treating your mother, and to understand what her diagnosis and prognosis are, which is why we think you ought to go to the hospital. But it makes no sense to make waves unless you have a reason to make waves. </p>

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<p>And if she doesnt meet criteria by Medicares definition for continued inpatient care, they will not approve additional days. The hospital cant keep her if she doesnt qualify for continued inpatient care by THEIR definition . </p>

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<p>Dharma, my dad was a faller. There were a number of reasons. One was simple body geometry; he was quite tall but most of his height was in his legs, so he was top-heavy. Second, he was on several drugs which affected his balance and coordination. And he had some peripheral neuropathy, so feeling in his feet was somewhat impaired. Those were the physical predispositions, but they weren’t the biggest problems. These were:</p>

<p>He had moderate dementia, so I think he honestly didn’t remember the hundreds of times he’d been instructed/reminded about using a walker. He had his share of male pride, and somehow figured that if he didn’t use the walker, no one would know he had problems with balance and walking (as he shuffled and teetered down the hallways). And I think he also honestly believed he didn’t need the walker. That makes no sense – he fell literally dozens of times during the 4 years he was at AL – but that’s what he believed, and he could not be convinced otherwise.</p>

<p>He was a brilliant man before the dementia, and could still rattle off nuclear physics equations if asked. But he never had a lick of common sense. </p>

<p>I think there was also an element of fighting against what I’m sure he knew was rapid deterioration. As long as he could walk, he could see himself as being OK.</p>

<p>Then there was the rebellion factor. All these people – doctors, nurses, PTs, AL aides, wife, daughter – were constantly at him to use that @#*$! walker. I think any time he got away with not using it, he felt that he had “won” – and if that meant occasionally ending up on the floor, that was a price he was willing to pay for victory. (Strangely, he never had an injury which required medical care, until he broke his ankle in a fall last July. That was the beginning of the downward spiral.)</p>

<p>And finally, there was the force of habit, which is powerful for all of us but even more so for the very elderly. They do what they’ve done all their lives. It’s tough to learn a new habit at the age of 84.</p>

<p>Here’s a partial list of tactics we tried. None of them worked:</p>

<p>Continual reminders
Putting up signs in the apartment
Putting signs on the walker
Making copies of signed doctor’s orders and posting them all over the apartment
Emphatic verbal instructions from healthcare providers, multiple times
Meetings with AL muckey-mucks
Pointing out that if he broke something in a fall, he’d end up living in skilled nursing
Placing the walker so that he couldn’t avoid it when he got out of bed (he’d just push it aside)
Begging and pleading
Trying to explain the logic</p>

<p>In the end, I had to accept what you need to accept about your mother: It is what it is, and nothing is going to change it. There was quite literally nothing that anyone could do to make him use the walker consistently. Nothing. </p>

<p>Your mom’s rehospitalization is not going to “teach her a lesson.” No amount of reasoning, nagging, or pleading is going to change her. No amount of falls in the bathroom is going to change her. Nothing is going to change her. Please understand and accept that. It will save you a lot of frustration.</p>

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<p>LasMa – that is deeply true. And sad. But, true still the same. We might wonder what would have happened if Adele had gone into assisted living when she was stronger four months ago, but it is what it is. </p>