Mom rehab to home transition. Any advice?

When you choose Medicaid at home, she will get visits for a few hours for personal care help for a few days a week, the rest is on who lives with her. If you cannot provide the rest of her care, then she needs to go into a facility that has Medicaid beds. If you think she hates rehab, she will also hate long term care and I am sure she hates her health predicament. At this much time has passed, her ability to fully heal has plateaus. Do not pay for her care with your personal funds. Let rehab know of an unsafe discharge. The social worker should help you fill out the paperwork

Has anyone told you what has caused this sudden dire change for your Mom, Orange? Was there a heart attack? (You mention fluid retention). Has anyone told you that Mom has a failing heart and CHF resulting with shortness of breathe and fluid retention? Is the incontinence also new? Is anyone having explanation why a woman who was driving now is unable to walk?

This is all sounding like a dire change for your Mom and I am concerned what doctors have told you about her prognosis going forward. It does sound now as though your Mom, at least for the present, needs 24/7 care, care that you may or may not be capable of physically and mentally. I wonder if you should not reach out to discharge planning as if in facility placement, at least for right now, might not be the only safe move? While Mom is in care at rehab or hospital the social workers can help you work out her assists, her abilities for self pay or application to medicaid. It is often the easier was to find admission into long term care.

I may be missing a whole lot here, that you can inform me of. Meanwhile let me say how sorry I am you are facing this. You have to be a bit in shock at the moment. I want to welcome you to the forum and let you know how sorry I am it is under these circumstances.

"She's always been independent but now is struggling with mobility."

This is the challenge of older age. Either the brain or body (or both) start to wear out.

"She HATES having the adult briefs on and HATES the rehab".

Good. Anger is energy!
I've found when people feel strongly, when they HATE something, then can use this as motivation. (Way better than those who give up).

HATE for the idea of needing adult briefs? (I'm assuming incontinence underwear?) Maybe use that energy & redirect to pelvic floor exercises?? But realistically, at 87, many need a little protection in that area. If she has not needed them so far she is doing way better than most people! Not being able to get to a toilet in time is a 'functional' reason, rather than a bladder or brain issue (if that makes her feel better). Practical solutions include easy clothing (think skirt or trousers with elastic waist, no fiddly zips). Also discreet pads that can be replaced as needed during the day.
My slogan would be *Hey that's life. No biggie*.

HATE being in rehab? Redirect into energy towards achieving rehab goals. Towards GETTING OUT of rehab.
My slogan to Mom would be *Keep going. Keep up your good work!*

"Before this she was living in an apartment we built in our basement for ease of living for her".

So aim for home as first choice.

"She is 87 and was driving, shopping etc. before this."

It's a lot to lose right? No-one likes to lose things. I'd say if we can't - then what CAN we do?
Can't sail a yacht - CAN take a cruise..
Can't drive - CAN get a taxi?
Can't shop - CAN get groceries ordered & delivered?

Can't do everything we used to do.. but if she can arrange it, organise others to help her, then this is also still independent.

The pathways will become clearer once rehab progresses. Plan A: Home. Back to functioning independanly.
Plan B: Home + accepting home services.
If that is not available/affordable/accepted, that leaves Plan C: into supported accomodation.

This will be her challenge. To adapt her living arrangements to the reality of her needs.

I think I am one of the very few where their parent excepted adult briefs (like that) with no problem. Ever since my Mom had my brother at 32 she had incontinence problems (She had 4 kids) she always wore a pad. At the age of 87 she was in rehab and guess they didn't have pads so gave her the adult briefs. She loved them. Never wore panties after that.

Hope your mom keeps that fighting spirit. She could possibly have some delirium or on medication that is draining her energy. That happened to my mother. The rehab was giving her valium plus a bunch of other unessesary medications. Medicare pays for skilled nursing at home if it's still needed after mom is discharged. My mom fell in rehab so we brought her home to finish PT/OT.

Rehab will set her up with home OT, PT & speech. You will have a visiting home health nurse to check in and maybe an aid to shower her once a week or so. Will you be able to care for her 24/7? They will make sure you have the tools she needs to help her move & transfer. Medicare will pay for some of the things needed like a wheelchair or walker.

She may benefit from a hospital bed and a bedside commode.

OT, PT can teach you how to help her transfer but that will be a lot on you physically.

If at all possible you would greatly benefit from additional help whether its hired cna's or family members.

Check with her primary about medication change for her arthritis.

The best of luck to you. This will be a huge transition for everyone. Been through it with parents and now a 94 year old aunt.

Always glad to answer questions and help.

Is she paying for the current rehab time out of pocket? Or is she still under supplemental Medicare coverage? Does she still have covered days left and she just wants to go home? Honestly, if she is making progress, I wouldn't bring her home. If they are ready to discharge her because she is out of days, that's a little different because she will have to pay out of pocket. But if she still has days and they believe she is making progress, I wouldn't bring her home yet. I would insist that she continue to work hard at the rehab and build up her strength so that she can come home.

Here is why - while a lot of people that are motivated come home and do home PT and OT and get back to themselves. There are plenty that come home and if they are not anywhere close to their normal strength - they might do home PT and OT halfway - not do the exercises in between visits. And they start to lose the momentum they were gaining in Rehab. It hurts too much to do the exercises. And then it hurts too much when OT and PT are there. And contrary to popular belief- the OT and PT aren't going to make them do anything they tell them they "can't" do. Even if they they know they can. If they tell them they are hurting, they won't push them because there are liability issues. They just mark their tracking that the patient was in pain and unable to attempt the therapy.

That fear of falling - I get that. I think it is very normal - Especially when their entire life has been disrupted by a fall.

Right now she is where she can get constant attention, daily PT and OT. I know she wants to come home. My FIL has been in rehab since a trip to the hospital at Thanksgiving. He was discharged at the end of January. He was out of rehab for 106 hours and promptly fell again and went back to the hospital for another week and back to rehab (he had time left because they discharged him earlier than we felt comfortable with, we didn't feel he was ready.) But a lot of it was because he was not really ready to come home when they discharged him the first time. And we were going to send him back to the same place - they wouldn't take him back (not couldn't, wouldn't - they said they couldn't get him any closer to his baseline). He has been in a different rehab now since the middle of February and he comes home this week. By all rights- he should be back at HIS baseline (which is the bare minimum to come home really)

He will be getting several weeks of PT and OT 2-3 times a week. And weekly nurse visits. Along with his regularly scheduled bath aide 3 times a week (via the VA) and the Social Worker at this rehab has suggested and started the process for palliative care to get him a more coordinated care plan.

Falls happen - there isn't too much outside of the obvious that you can do to prevent them. (removing obstacles, installing bars where necessary, ensuring floors are dry, making sure they are not wearing slippery socks, , etc) She will probably be scared to shower as well. But if she can stay a little longer it will probably be good for her. Even if she hates it - FIL certainly does. But we regret letting them discharge him when we did because we had to start all over again. Even though they didn't really give us much choice (BIL/SIL live with him and are his full time caregivers) They advised that they had to discharge so we took him home. If we had known what we do now I think we would have tried to push back some to test the waters.

Interesting mom went to rehab and then hospitalized then back to rehab. My wife fell and had to have two major operations, five days in the hospital then off to rehab for sixty days. We had straight Medicare and a supplement. We did not receive a single bill. When she was discharged we had home rehab three times a week for months which was very helpful. Again no bill, straight Medicare and the supplemental covered it all. If you can arrange it I feel the rehab both PT and OT in the home environment was most helpful. With help Mom should regain her strength and become almost fully functional. If she is going to continue living in the cellar you might want to have a ramp put in instead of stairs and of course grab bars all over. Good luck and it’s obvious you are a loving daughter.

Your best direction on what in home services will best meet her needs and when , as well as who pays for what will be best provided by the case manager/ discharge planner for her. If they are competent and doing their job,they should be able to provide direction. Do not let her( pt) guilt trip you into bringing her home too soon! This will only lead to potential other injuries or challenges unable to be met at home.
Explain to her that this is all about her " safety" first..... Speak with her PCP also .....and the facility staff for input on present status and expected progress, recommendations etc.

Practice good self care....you need it and deserve it......

I was a son who went through a similar situation with my mom. She was active well into her mid-80's and still driving. That changed after her hip surgery. She was in a local nursing home for rehab for about a month. Twice a day visits were crucial to make sure her "care plan" was followed. On one visit, when she was supposed to be at PT, she was laying in bed in the dark. I made it clear that was unacceptable. I ended up going to following PT sessions with her as I knew I would be taking on the role as caregiver when she came home.

Before being released, I made arrangements for a temporary ramp for our home (later a non-profit group built a nicer one), a walker, a wheel chair (which was used more later on), and a portable commode. Medicare covered most of the cost, including a set number of home PT visits. As time went on, it became clear we needed more assistance, so with the guidance of our County DSS and Office for the Aging, I submitted the application for her to be covered by Medicaid. Under our state's Medicaid Managed Long Term Care program, she became a "dual eligible" (Medicare-Medicaid recipient). Cost for pull-ups, absorbent pads (for bed and chairs), medication (co-pays, if any very low), and a weekly visit from a home health aide were now covered. As part of the process, a pooled trust was required, which allowed her Medicaid spend-down to be used for payment of selected monthly bills.

Having the assistance of Medicaid allowed me to concentrate on keeping my mom comfortable at home. As I have said on previous posts, being her caregiver was the most challenging (physically, mentally, and emotionally) job I have ever had. But it was the most rewarding. She lived to age 93. As you see by the responses already, there are many who understand your predicament. This was my journey. I wish you well with yours.

Elder Law Attorney will educate you and help you strategize the changes coming and Medicaid..

There are many types of walking canes to help the patient maintain a sense of balance and to help them s-l-o-w down.

A geriatric urologist can help medicate for urination issues.

A Gastroenterologist can medicate to stop incontinence.

medicare no for an aide. medicade yes for an aide, call your local dept. of aging. tough situation if she cannot walk tell her.

Explain that she will have to work hard at the rehab in order to get moving again. Talk with rehab about getting her out of bed to go to the bathroom. It's common for them to slap a diaper on patients because it's easier for them - not her - just no time consuming for them. They actually have bathroom training to get them back on a toilet. They should be able to help her onto a bedside toilet at first - yes it will take staff longer in her room - but request that it be part of her rehab. She didn't come in there wearing a diaper and you need her to be able to, at the very least, get on a bedside toilet. (After diaper, you really do have to retrain the brain to know that it's not normal to use the bathroom in your pants. At first, patient will push call button over and over because they have to go. Then they can't hold it any longer. The more often that happens, they more your brain accepts it as normal.)

It's unlikely she can live in the basement for a long time, maybe never. Getting up and down stairs may not happen in the future. Especially with arthritis. However, if she can get around on an upper floor with walker, it will be big improvement over where she is right now.

Home care from Medicare will be something like weekly nurse visit, physical therapy (lower body) and occupational therapy (upper body) a few times a week. Medicare doesn't provide actual in home care. Medicaid (if her income is low enough to qualify her) MIGHT give her a few hours a week for things such as bathing, dressing, etc. Medicaid has a few in-home programs to help keep folks in the home, but hours are very, very limited. You aren't going to get full time hours if that's what you're thinking about.

People who cant' afford home care just don't get it - family provides the basic 24/7 care that might be needed. You should be able to go online in the area where you live and do an income calculation for potential Medicaid in home programs for elderly/disabled. Or do an application online. If she's over the limits of income and/or assets (like bank accounts, property other than her residence, etc), then it might be time to visit an elder attorney who can tell you what counts, if it can be turned into a trust, and how much money in the bank she has to spend down in order to be eligible for Medicaid home programs or NH care.

orangemonster99: Welcome to the forum! I'm praying that your 87 year old mother can regain her strength via physical therapy. While many elders do not relish wearing adult briefs, they will save many a toileting accident. Perhaps she can be encouraged to continue PT so that she can return to her independence, but it may take some prompting due to her age and the fall event.

I feel for you and your Mom. At 97, my Mom was independent (not driving though) fell and two screws were placed in her upper leg bone. We put her into an aggressive rehab hospital for 11 days (maximum time she could stay there), and she was walking with lots of help and in severe pain. From there, she went to a normal rehab hospital, where they did not challenge her. The PT guy said that she was lucky to be functioning [for a 97 year old] and basically just stopped trying to get her to walk. His diagnosis of "she is doing as fine as she can for her age" caused Medicare to not pay for additional rehab. It didn't matter that she was completely independent prior to the fall. About 8 weeks after the surgery, the doctor who put the screws in, declared her healed. However, from my perspective, she had regressed from the original rehab hospital, in the wheelchair for mobility, was always in pain and a zombie.

I bought handicap bars for the toilet area and a shower chair. We installed a hand held shower wand so that she could still take a shower. I took her home.

My Mom learned to go from one room to another via wheelchair (actually, it was a transport chair so it was lightweight and easy to move). We kept the legs off the wheelchair and she would move her feet against the floor which would move the wheelchair. (We had lots of wheelchair marks on the walls and cabinets from this.)

After 4 ER visits, a doctor finally told us that it was her arthritis that was the source of the pain (the clue was that her pain was NOT in the area of the surgery). They had assumed she knew this since they assumed that she had pain from arthritis before falling down. His parting words were "You need to go home and enjoy the rest of your life." (She was in so much pain, there was no enjoyment.)

After the knowledge that the problem was really arthritis, I concentrated on getting the pain down to a tolerable level. First off, I took her off of prescription pain meds. It turns out that her body was addicted to the pain meds, therefore the amount of meds that she was getting, no longer attacked the pain. I told her what I was going to do, to warn her about the change in pain level. In addition to going to OTC pain meds with assistance from doctor, I also started her on CBD pills (from hemp so no THC), which are known to help relieve arthritis pain. After about 2 weeks, the pain decreased and now she could concentrate on PT. To this day, 4 years later, she is on Tylenol and Alleve and CBD and the pain is reduced to a dull ache.

Once the pain was under control, we went to a PT person who had no idea what to do with an elderly 97 year old who had a crazy daughter who wanted this 97 year old to walk again (they don't teach you this in school.) I told him that I wanted him to do PT on my Mom as if she was a 2 year who couldn't walk. I was there for the entire PT visit. I asked a lot of questions about what each exercise did and why he did it. I also directed him to exercises that my Mom could do, and couldn't cheat on. I'm not sure if he was happy or annoyed that I was there. Each night, I did exercises with her. Within 4 weeks, my Mom was out of the wheelchair and was able to walk across the room. Within 8 weeks, she hardly used the wheelchair.

My Mom was a fall risk, so in the beginning, I was the only caregiver. However, soon, her behavior returned to the old behavior that annoyed me and I found abusive. So I interviewed with an agency and they provided people for 9 hours a day so that I could at least get some sleep. We removed ALL valuables from her house.

Now, I still put my Mom through a shortened version of these exercises, even though she is over 100 years old now. To get her to have confidence to not fall, in addition to the sit-to-stand, I bought a step board, and make her walk up and then down with her walker. For circulation (water retention), we use an exercycle with no tension.

Best wishes.

You should have meeting with Social Worker and Medicaid office at rehab. If she can’t ambulate or do basics what they call ADLs …activities of daily living, she should stay there long term. If she comes home, it will be a disaster…& she will not be able to function. Please don’t take her home. Hugs 🤗