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She's on home oxygen, noncompliant with meds and can't take more than 2 steps. Shes been there for 60 days and needs more skilled care. She's on Medicare. How can I convince them she needs to stay longer?

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Call and talk to the discharge planner about whether or not this is a "safe discharge"? Ask what the care plan is.
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Pattyreddp Feb 2019
Ive called, left messages upon messages. Im just at a loss. I cant drive there, Im recovering from neck surgery.
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I agree talk to the doctor in charge of her care. But realize that Medicare determines whether she stays or not. If Mom is making no progress, then Medicare will not pay so she will be discharged. They have done what they could.

She has a Pulmonary doctor, right. Call him and tell him she is being discharged. Drs.in rehab are not Specialists. In the meantime, you should make arrangements for someone to stay with Mom in her home or yours until you can make other arrangements.

The only other option you have, is to file for Medicaid and get her in LTC if she can't afford private care.
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ImageIMP Mar 2019
Actually, her option(s) actually include distancing herself and simply requiring that the patient services finds an acceptable placement... She doesn't have to assume responsibility for move/placement if she's unable (or unwilling). The authorities simply can't place Mom out on the street, and she isn't responsible for Mom, or her expenses/living arrangements, unless she's willing and able...
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Thanks!!
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Joan is correct...If she is on Medicare, they will not pay if she makes no progress or doesn’t cooperate during physical therapy. You should apply for LTC Nursing Home Medicaid for her as it will be very difficult to care for her at home. You will be doing most of the caregiving. See Social Worker and Medicaid office in rehab. Tell them you don’t want to give up your life to be a full time caregiver.
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kdcm1011 Mar 2019
Actually, she can’t assist with any caregiving upon discharge. She herself is recovering from neck surgery.
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You have of the option of refusing to take her. While it is correct she cannot stay indefinitely at a rehab, the discharge planner and social worker should work with you to find nursing home placement. Is it possible to private pay the the rehab until you have nursing home placement?
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Pattyreddp Feb 2019
No, shes on medicare and broke. She is at a state run “rehab” after being admitted to the hospital for shortness of breath. They are a medicaid nursing home and I was hoping they would keep her. Im not sure how they can send her home in 6 days without speaking to any family. She is very unsafe to be alone. She falls, forgets when she last took meds, abuses her meds, etc. former alcoholic, now abuses pills. Im just at a loss for words. Its an accident waiting to happen. She has no family and Im in no shape physically to care for her.
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Agree with the previous posters. The NH referral is for skilled nursing and/or rehab but Medicare will pay only as she progresses and or she hits her 100 days (20 days for complete coverage). If the care she currently needs is really more custodial (bathing, dressing, transfers, etc) then Medicare will not pay. You should have a discussion with the discharge planner as suggested about a safe discharge; it may have been assumed that she would be going home with you particularly if she lived with you or you assisted in providing care prior to her hospitalization so make them aware of what, if anything, has changed and why you consider it an unsafe discharge. Most facilities have an initial care conference with resident and family with in the first 10 days of care and then periodically afterward. Since Mom has been there 60 days already you may be a little behind on the schedule of things to have this conversation now but have it at any rate. They may have suggestions for you but be prepared that one of the things they may suggest if she cannot remain at home is long term care (NH). This is the most expensive level of care and few people can afford it out of pocket so a Medicaid application may be needed. I don't know what state you live in but most of the time the application process is rather long (think of it in terms of months) and will require the caregiver (you) to come up with various documents (birth certificates, marriage licenses, mortgage payments/rent receipts) and lots and lots of bank statements. In NJ Medicaid will take a 5 year look back over the applicants shoulder to see if any funds have been transferred or hidden. Gathering this information can almost become a full time job!
If this is the case, be aware that Mom may have to go somewhere while her application is being evaluated and that the current NH may not be able to keep her during this process. Get that meeting with the discharge planner as soon as possible.
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Patty; Is she on Medicare or Medicaid or both?

How did the facility communicate with you that they were discharging?

Are you calling the correct number?

If you can't reach them first thing tomorrow, call the local Area Agency on Aging and tell them what is happening.

Are they going to send her to her own home, or to yours? Is your home her legal residence?
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Pattyreddp Mar 2019
She is on medicare.
The facility called me wed and told me she was to be dc on tuesday. This was the first time I heard anything about a dc.
yes, I called 4 times yesterday and finally got the sw on the phone. I have a meeting at 2 today.
After reading all the replys Im assuming her time has run out at this facility.
She is my stepmom. Im the only one that had helped her but I am in no shape to care for her. She needs 23/7 nh care.
She is non compliant with all meds. She calls 911 for every little thing and ends up hospitalized for 3-4 days. This was her first “rehab” stay.
Hopefully I will impress upon them today how unsafe she is at home. Doesnt shower, lives in filth and abuses everything she gets her hands on.
I have tried for years to help but you can only help someone that wants help.
Im exhausted with her
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Patty, I don't know the circumstances of your Mom's placement for skilled care, and whether this involved an initial in-patient hospital stay? Depending, I'm concerned there could be Medicare issues you aren't aware of and probably haven't been told about... I know others have already mentioned progress requirements, etc., but... I'm going to try to give more detail and rationale involved.

Since she's already been there for 60 days, I'm guessing she's not on Medicare Part A, which is involved following an in-patient hospital stay? I know a LOT about Part A, because that's what my Mom was covered by for a period, but your Mom might be under "regular" (Part B?) Medicare, and I don't know as much about the requirements for Part B. However, it's worth your while to find out whether the rehab facility has to follow specific Medicare rules on when and how she can be discharged...

IF it's similar to Part A coverage, then Medicare requires an incremental assessment of improvement in rehab to continue coverage at that level... The facility "guesstimates" when that level is getting close to the Medicare cutoff, and issues a discharge date to the patient. In other words, they base this date on the facility's "prediction" of when Medicare will refuse to continue payment, at which point the facility would be left holding the bag... If this is the way Medicare works in your Mom's case, then the facility must give you a page - from Medicare - setting out your rights per this "planned" discharge. (For Part A, there is UP TO a 20-day initially 100% Medicare-paid period. After that, for UP TO another 80 days, Medicare will cover the stay but require a co-payment from the patient.) The catch is the "up to" clause, because Medicare requires reports from the facility documenting measurable incremental improvement from rehab/therapy. If this improvement stops, or slows down below Medicare's standard, then Medicare will no longer cover the stay. The bottom line is, this official Medicare "exit" notice sets out the option for the person responsible for the patient (with Power of Attorney probably?) to challenge the facility's discharge date/plans. You can contact Medicare directly, from info provided on the form, and file an appeal to the discharge date. Medicare will have doctors completely review the file - the patient's history, and current situation - and then decide whether the discharge is valid under their guidelines, or whether there should be additional care at the facility. If they "uphold your appeal", the facility has no choice and must keep the patient longer... This process can be repeated a number of times - the facility notifies you of a planned discharge date per their "guess", you appeal to Medicare, and await Medicare's decision. (The same appeal is available for a planned discharge from a hospital - you can appeal based on your concerns that the patient can't be safely discharged!) One interesting factor is that the appeal usually adds a day or two to the stay, just because of the time required for Medicare's decision.

So, ask whether the discharge date is mandated by a Medicare provision, and whether you can file an "appeal" to the discharge. If you are given a Medicare form - informing you of your rights - read it! It's certainly worth a try!
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Pattyreddp Mar 2019
Thank you. Im printing this out and will find our more today at 2. Im supposed to have a meeting. I called 4 times yesterday to get this. Im not sure whats going on at this facility. Absolutely no communication.
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Contact an elder attorney.
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It sounds like she will need nursing home placement. What sort of pulmonary rehab? If after 60 days she has not improved enough to care for herself then she may need the 24/7 NH care.

You are family - call them. You’ve been alerted to DC in 6 days. Have you attended care conferences in the last 60 days to discuss your mother’s progress? This should not be a surprise.

As stated, Medicare sets the date - not rehab. If rehab isn’t being beneficial then it’s LTC NH & Medicaid. You will have to assist their SW in getting the forms filled out finance wise.

Medicare does have a Co-pay after 21 days thus her stay now is not 100% covered by Medicare and hopefully her supplemental plan will pay for this.
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Pattyreddp Mar 2019
We had one care plan meeting at the beginning. They called me to schedule a meeting last week. I was there, waited an hour, told 4 people I was there for the meeting and nobody knew a thing. Terrible communication on their part. I drove 45” for this.
yes, she does need 24/7 NH placement. She has copd, on O2 for 3 years. Cannot do her treatments or take meds correctly. Im shocked nobody discussed her dc plans with me. Im the only one she has and I have tried for years to help her but I am in no shape any longer.
Thank you for your reply!
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Speak to the administrator of the facility. That no one is contacting you or returning calls needs to be addressed. Sometimes they don't know people aren't doing their jobs unless someone tells them.

If they won't talk to you could it be that they don't have a copy of your MPOA? HIPPA laws are applied to every person unless they verify you have the authority to get info. If you aren't authorized they won't speak to you.

Call the ombudsman and have them help you, they might direct you to resources or intervene to get a safe discharge in place. I had to stand my ground because the rehab was pushing for discharge and my dad had no safe place to go. It was awful but stay strong and keep repeating that she doesn't have care and needs a safe discharge plan. My dad was telling everyone that he had a place, my house, and I was screaming no he doesn't, could this be what is happening in your situation? You could have your doctor write an excuse letter stating you are unable to care for her.

I hope you recover quickly and well from your surgery. Sheesh, this situation is the last thing you need. Be strong and don't let them bully you or just dump her out.
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Pattyreddp Mar 2019
Thank you for your wonderful advice. I have a meeting at 2 today. Hopefully I will get someone to listen.
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And ask that she be admitted as a long term care patient "Medicaid Pending". Ask for help completing the Medicaid application.
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Pat, if they "threaten" that the state will take over her care, say "yes thank you".

You can't help someone who doesnt want to be helped.
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She needs a neuropsych evaluation or may just a geriatric psych evaluation to confirm that she is unsafe at home. They need a diagnosis of something like alcoholic encephalopathy or dementia to work with to confirm she is unable to care for herself due to cognitive dysfunction. She needs to have competency determined and have a POA or guardian established to make decisions for her. otherwise, she could just be allowed to make her own decision, call 911 again and end up in hospital again. If rehab won't help coordinate this, they they are stuck with a plan for her and may just decide she is compenent.

Note to all, when you have a LO in hospital or rehab, enjoy the break but start working on discharge plan immediately. Your house does not and should not be the discharge goal, but don't expect the hospital to do the heavy lifting for you. If you don't think LO is competent, ask for an evaluation while in the hospital so they can confirm that. Otherwise, if person is felt by hospital/rehab staff to be able to make their own decisions, they can just send them back to their prior living arrangements. While it is usually obvious to family that person cannot life alone safely, it may not be obvious to caregivers.
If family member is still at home, and doing fine, then read Being Mortal and then have the hard discussion with them, get the POA done and don't be an ostrich or allow them to be.
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Patty, how did the meeting go on Friday?
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Everyone keeps saying about it being your mom but since you did say it is a step relationship this may or may not have been a close one . Regardless you are not responsible for her unless you have taken this on willingly - and be aware that you def should not accept financial responsibility unless you clearly have those means which I assume you don’t . You actually have no right to even access her records and documents unless you have received that legally so of course you don’t need to fill out applications the sw does . As a kind person your only responsibility is to make them awAre that she is on her own at home and that she can’t manage - through her present facility and the area agency on aging . Then you can go visit her on occasion as a friend .
You have been kind to help her but you don’t need to go above and beyond especially since if she does actually have living relatives this could come back and bite you in the future if they claim some issue with how you mishandled anything
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Medicaid takes months before it's approved...it took 8 months because they found all kinds of things, and wouldn't approve it.. I think they do that on purpose so they get more money.....2 months later my mom passed away. It's all a racket and most elder lawyers are useless.
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Thanks for all the advice and answers. I went to a meeting friday and they told me in no uncertain terms shes going home tuesday. They dont have a bed for her. I met with 6 people that met her once and had no answers. A nurse will come in and assess her to see what help is available for her. Im really done with this stress. Amazes me
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thepianist Mar 2019
You have a right to appeal this decision. Please talk to her social worker and at least insist on an appeal. The problem, unfortunately, is bigger than one insurance company or one hospital. It's our whole US healthcare (I use that term advisedly) system. Best of luck.

PS: Be sure they checked with other nursing homes in the area. They are supposed to do this.
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How will they discharge her? Don't pick her up!
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thepianist Mar 2019
When my 85 year old aunt was to be discharged when we all thought she should not, i refused to return to the ER to pick her up. They sent her home at 11:3o pm IN A CAB, in her hospital gown and a light coat on a November night. And this was a good hospital! And when I wrote to the state health dept. they said this was all within hospital protocol. So I agree, Don't pick her up, but they might try to send her home on her own. Compassionate care is not the priority these days in hospitals. It's making sure the insurance bodies won't be upset with them.
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Patty, does she live alone?
Are they saying that she is okay to go home alone with home health?
Do NOT pick her up. Do not sign that you agree to discharge. Let her sign for herself.

When they send her home, call Adult Protective Services and ask that they conduct a wellness check.
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Pattyreddp Mar 2019
No, I cant pick her up. They will provide transportation for her and charge her $50. Im still at a loss for words but time will tell. She will be calling 911 within a week or 2, then back to the hospital. Im really done with this horrific system. Very sad!
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It may be a insurance issue. Medicare will only pay for X number of days of rehab for a specific problem.
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Someone there should have Discussed this with you before Talking about Discharging her. You need to speak to Someone, Hun, And Soon about Caring for Her in her Own Home or in a Facility such as Skilled Nursing.
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Good luck! Speak with her doctor and the social worker at the rehab and tell them your concerns. Is she eligible for hospice?
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Something like this happened with my mom. I actually got help from the Senior Linkage Line. They have been a godsend for me. They put me in contact with home health, help with getting medication refilled, etc.
My mom has had 2 heart attacks and a devestating stroke. She is unable to live by herself, cannot do ADLs without help. The Linkage line also calls monthly for updates, any help I may need and just to make sure we are ok.
Is worth a try!
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Medicare only pays for so many days (I believe it is 100 days maximum). it's rehab--not permanent placement. Further, they have to chart some kind of improvement in order to stay in rehab. If she does not cooperate with physical therapists they will chart "refused" and it's back home. It sounds like she needs permanent nursing home placement. Contact a social worker to get her on Medicaid; however, another option is hospice. Medicare pays for hospice.
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ImageIMP Mar 2019
I previously explained this process in detail... Yes, Medicare (Part A, probably) will cover up to 100 days in rehab/skilled nursing following a hospital stay. (UP TO 20 days all-paid and UP TO and additional 80 days, with a co-payment) The facility, though, decides at which point Medicare will deem the patient isn't making sufficient rehab progress (and not pay after that), and the facility schedules the discharge date. (They "guesstimate" this date to be before Medicare stops paying, but that's what it is - a calculation on their part.) They should HAVE to provide a Medicare-rights sheet at the time of discharge notification. This will have the process, and phone number, for appealing the nursing home's discharge decision and date. You (your step-Mom or responsible - POW - person) has the right to appeal the discharge with Medicare. They will have medical and rehab records reviewed by medical personnel, and decide - within 48 hours - whether YOUR appeal will be upheld, and the patient allowed to stay for an additional period, or whether the discharge is proper as scheduled. This process can (and probably will) be repeated a number of times, and the same options are available each time. (I appealed my Mom's discharge 3 times, was upheld, and she ended up staying for 96 out of the 100 days! - apparently almost a record, because the facility was really shocked!) When she is to be discharged, you do not have to take her in - cover her costs - even make arrangements for placement. You can "warn" them that if they place her in an unsafe situation (for instance send her home if that isn't safe and appropriate) you will scream bloody murder to Senior Protective Services. Keep a journal/record of everyone you talk to, what was said or decided, dates/times/etc. - and keep a record of any valid requests you make that are ignored, and any care meetings, arrangements, promises, etc. they make that they don't follow through on! Keep a record of everything!
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From my experience with a similar situation, if you feel that you are unable to keep your mother-in-law (SAFE) in her present condition this should be a very valid reason.
Make sure you emphasize SAFE. No facility will release a patient if caregiver cannot keep them safe.
Hope this helps. Good luck. 🙏🏻🌹🙏🏻
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When someone is going to be discharged from rehab in a long-term care facility the home must give you a "Notice of Medicare Provider Non-Coverage" form to sign. This is a Federal requirement and must be given 48 hours prior to discharge from Medicare.This form simply says that the resident is being discharged from therapy. If you feel that your loved one is being discharged to soon you can appeal this notice. The form will have the number where you call to appeal. The appeal is done by a third party, not the facility staff.

The appeal will be completed within 48 hours so you don't have to worry about additional cost.

If the reason for your loved one being discharged is that they are refusing therapy you will not win an appeal.

The social worker at the home should be working with you to establish a discharge plan. They cannot discharge her to an unsafe environment.

I hope this helps, good luck!
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ImageIMP Mar 2019
Yup - just what I described/explained earlier in a more long-winded, detailed manner! Don't let the bureauocrats bully you around! Know and excercize your rights!
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They are not supposed to release her to an unsafe environment.  If she cannot walk, then it is not safe for her to be home alone.  It seems they should work to set up home health care for her.  Ask if they have a social worker who could work on that.  If not, contact a home health agency to see if they will try to get her approved for their care.  Another possibility is one of the care assistant agencies like Visiting Angels, Right at Home, or a similar group.  They could place someone in her home to assist her.  But, getting Medicare to pay is an obstacle.  Good Luck!
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Check with the insurance company. An appeal can be filed which will buy you a little bit of time. You will have to consider putting her into a nursing home facility or assisted living. You could bring her home and hire caretakers but if she isnt walking I wouldnt recommend doing that. The insurance company can tell you what rehab facilities are available near you. You are the advocate so fight for the care that she needs. Another person to help guide you is the social worker...discuss options with the social worker. Good luck!
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ImageIMP Mar 2019
I don't know about an insurance company helping with placement... (I think she stated step-Mom is totally on Medicare?) But - in any event - if you choose to become integrally involved, don't just rely on ANYONE'S referral/recommendation! Check things out for yourself - read online reviews (and pay attention to who is leaving those reviews! Facility staff aren't exactly reliable?!) When my Mom was hurt, had surgery/discharged to hospital in 4 days, I was totally at a loss as far as placement options... She needed rehab/skilled nursing, and I personally checked a couple of places out (which is only minimally helpful when touring with the "marketing manager"?), and then relied on the recommendations and opinions of the hospital social services staff and "A Place for Mom". Mom ended up in a beautiful, new, horrible, abusive, and neglectful facility, which damaged her beyond recovery - literally - in less than a week. I didn't find out until afterwards (per reviews and personal contact from prior patients, families, and other community sources) that this place is well known for neglect and abuse... I learned that "pretty and new" doesn't necessarily equate with "competent and caring". I ended up moving Mom to another facility (managed by Benedictine Nuns!) which was frankly run-down and pretty sad per physical inspection, but abundant with good care and caring staff (and a good community reputation). Knowing what I know now, I would even go so far as to inquire with a local Social Media site (yes, even local community FB groups) per peoples' first-hand knowledge, experiences, and recommendations. Then put all this info in a "pot" and make your own decision! (This process really doesn't have to take that long when you don't physically run around to all the local "options", but winnow it down to a few most-likely to work!) Sadly, I wish I'd learned all this when it mattered to my Mom...
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Go to the business office and get an application for Medicaid Long Term Care today. If she owns her home, check off the box that says that she plans to return home. Apply for Medicaid if you think she has low enough income and assets to qualify. It is my understanding that once she applies for long term care, they can't discharge her unless they feel she demonstrates all the daily living skills necessary for living independently. If there is a move to discharge, appeal it. If they deny the appeal, appeal that. Also, at your meeting, request a home assessment. This is done while she is still a patient at the rehab facility. She is driven by you or a handicap van to her home, and the physical therapist follows in his/her own car. They observe mom enter the home and maneuver about the house. This observation will inform the professional what the patient will need to return home (ie. grab bars, bed rail, room for walkers, hospital bed, ramps, etc) They can assess how competent she is while ambulating. This process proved very helpful for my dad on two different occasions. A good physical therapist will recognize great interventions and also inherent risks. I suggest you record this on your phone for your reference. If at some point she is discharged, apply her immediately for whatever Community In-Home Medicaid program your state has. Massachusetts has something called Frail Elder Waiver. Programs like this can provide up to 18-20 hours a week of in-home help. Once she is on Medicaid and a Frail Elder Waiver type program; it can take quite some time for them to process the application. My mom was able to benefit from frail elder waiver which allowed her an automated locked med dispenser, life-line, and help 5 days a week divided between mornings and supper times and qualified her for adult day care although she never partook of that. This allowed her to live "independently" for over two more years. Yes, I did help her too, but it was doable. When she landed in rehab after breaking her hip and wasn't participating enough for Medicare to say she could stay, the Frail Elder Waiver assessment nurse clearly recognized that mom would need too much care to return home and okayed her for up to three more months in the facility. (As an aside, I would like to see a Medicare appeals person break their hip and only address the pain with Tylenol and perform the level of physical therapy they expect. It would be very difficult at even half the age of my mom!) For some individuals the extended stay can allow for them to improve enough at a kinder pace in order to go home. If not, a long-term care application is completed. Your mom might require hospice. This can be provided in the nursing home. An in-take nurse will determine if she qualifies for hospice. I was in your shoes back in 2014. I knew nothing about anything. Hopefully, you will find a kind business office person, or social worker who will show the way. My guardian angel for applying mom and dad to Medicaid was a hospital administrator where my dad had been a patient in the recent past. The business office at the rehab/nursing home helped with the Long-Term Care applications for first my dad and then my mom when the need arose. The community elder outreach person also was helpful. Keep asking questions, advocate, and persist. Good luck with everything.
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