My dad had an occipital hemorrhagic stroke two weeks ago. He was in the ICU for a few days, then discharged to inpatient intensive rehab, where he has been since the evening of 3/22. My mom got a call from them today, telling her that he will be discharged on 4/1 at 11 AM and that’s it, even if he still can’t walk.
We will have to come pick him up somehow and drive him home and somehow get him out of the car and into the house, likely without his being able to walk.
That’s all they said. There’s no social worker or patient advocate? Nobody to give us any information about what steps to take next?
I work full time, and my mom is 80 and can’t possibly take care of my confused, non-ambulatory dad all by herself most of the time. He can move all four limbs but not walk, and he’s lost the vision in his right eye. He gets easily confused and has trouble speaking, though he is more fluent at some times than others.
Is there something we can or should do? He has Medicare and letter carriers’ insurance, which apparently doesn’t pay for shit.
Well, that is just crappy.
I can’t believe the rehab place doesn’t have a patient advocate.
First, call your father’s PCP. Then the neurologist office.
If that doesn’t get you anywhere, does your county have an Agency on Elderly?
Next call Medicare and his insurance through the post office. See what their deal is.
Something may not have been transcribed or missing from his chart.
Failing all that..park your butt at the hospitals social service persons office.
My wife works at that type of place. It’s not designed for long term care. It’s supposed to be a transition between hospitalization and either home or long term care. Insurance will not pay for longer stays. Where she works there is a social worker that tries to help with the transition.
My aunt was once in a similar situation. She got to a point that she would not cooperate with physical therapy because it hurt and she preferred to stay in bed.
Then we had to make alternate plans. With no physical therapy, they could not bill for rehabilitation. There was a separate section at the facility for medicare patients, but she was determined to go home. That was a more expensive option, and it required her doctor to enter her into hospice, but it was doable.
I do understand it’s not long-term care, but I thought they would give us a little more assistance with figuring out what to do next - nursing home, home-home, medical equipment needed if at home, etc. But they just basically called my mother and said he’s out the door on Tuesday at 11 and gave her the “you’re on your own” vibe. I guess I’m naive, but I thought they’d have a social worker or something.
He has original Medicare parts A and B, not Medicare Advantage. He also has NALC (national association of letter carriers or something like that), which I guess is supplemental insurance.
He had the option of going to the rehab floor at the hospital or going to this standalone facility, which is closer to our house, so we chose the standalone facility.
His PCP has been fuck-all help. We couldn’t even get a call back when we tried to tell them he’d had a stroke. We do have an agency on the elderly, I believe.
Maybe your Mom missed part of the convo. Or didn’t understand it.
You may as well take off Monday. Maybe Tuesday, too.
Be at the rehab facility 8am, Monday morning. They’ll have someone there.
If they are no help.
Find and get him a referral to a longer term facility.
PM me your regional location and I’ll send you phone numbers to rehabs in the area.
I went through a similar process with my mom. She fell and was admitted to a hospital. After a few days, the hospital sent her to a rehab facility. The rehab place made it clear that after they discharged her, it was up to me to find someplace long term for her. I was somewhat shocked at the lack of support available for someone in that situation. It took me several weeks of full time work to research and visit various long term care facilities and nursing homes until I found one that was not terrible and was also willing to take her (she was sometimes combative with staff, which greatly reduced my options). As it happened, she died within a week of moving to the nursing home.
You will need to determine what type of facility is appropriate; it sounds like you may need a nursing home if he’s unable to walk. I wasted some time looking at assisted living and long term care facilities before I understood that nursing homes are a separate category and that’s what my mom needed. You should definitely explore what social services options are available, although in my case those options were not helpful. There are a few organizations that might help, like A Place For Mom and Caring. I did get some leads from A Place For Mom, although in the event the one I chose didn’t come from them, although IIRC it was recommended by someone I connected to via A Place For Mom.
The unfortunate news is whatever you choose is going to be expensive and insurance will probably not cover it (yay US health care). Doing this on a tight schedule will be difficult and stressful. Good luck.
Nobody at the facility even seems to be able to tell us if he is ambulatory with assistance or what. That’s probably partly because it’s the weekend, but holy hell, they tell you your loved one’s butt is hitting the curb on Tuesday and don’t even give you any information or time to figure out what to do next!
My dad himself doesn’t know if he can walk or not. He doesn’t even seem to know if he did any physical therapy on a particular day. The nurse today told us he did work with physical therapy today, but he told us he didn’t.
I’d also consider a Nursing Home with a good Physical Therapist. A patient can get 60 or even 90 days of PT. It depends on insurance.
Many go home afterward or transition to long term care.
My mom went into a nursing home in 2017. PT helped her get home 3 months later. Medicare paid. She was home for another 4 years before going into long term care.
My mom’s social worker helped us find a Nursing Home with a separate hall for PT patients. The rooms were setup to meet Medicare requirements. These were single patient rooms. Mom saw a physical therapist 3 times a week.
My wife’s facility does have a social worker to help. But even with assistance it’s still the responsibility of the family to figure out the next step. It mostly comes down to what your insurance says. There are different levels and types of rehab. My wife works at a sub-acute rehab which sounds like what you are dealing with. The level of care is designed for short term stays. Often the patients are going into long term care.