Can I refuse to bring my Dad home from hospital and demand he go to a SNF?

Yes, much of what you say is true. And do the ambulance thing. That is how it works. They have to admit him to the hospital and they can't discharge him if they know either no one is there to help him or it is unsafe environment. You might not have your choice of a SNF and that can be scary, but sounds like yo know what is best. Careful on the medicare to medicaid part though. Two things: Medicare will pay for more than the 20 days and more if he continues to improve. If he plateaus, which means he stops improving, then it becomes private pay or you start the Medicaid application process. It takes months and months to get Medicaid approved AFTER you have done all the leg work of mounds of paperwork and paying down his assets. There will be a 5 year look back period. Read up on this. Too much to type. I know it is hard, I went through it with my Dad, now in a NH and I will probably go through it with my Mom and no sibling support whatsoever. I have teenagers and run a small company. Oh yeah, a husband too who deserves better than the currently situation.

Good luck and stay strong.

xo
-SS

Pyrrhe, not sure where you are at in Alabama, but I worked with a Sava Senior care facility in Houston, TX to place LO in a medicaid pending, I see that they do have some facilities in Alabama- I was in the same situation not able to pay the 4,000 to 6,000 for private pay so I was limited to a facility that would take Medicaid Pending. It is my understanding that the states requires some of the facilities to have both Medicaid Pending and Medicaid beds available but it is a limited number.

My LO was falling two to five times a week at home, not able to walk or get himself up and down and was totally incontinent, plus weighs 300 lb and I'm am only a third of that, I was his only caregiver and had to leave him alone while I worked which was just not good. I wanted him in a facility for his safety. My situation was such that my health was declining taking care of him by myself while trying to work and take care of all of my chores as well, it was just too much for me and could not afford full time help to care for him. I took him to the ER a number of times after his falls, they always just checked him out and sent him home, so waiting until he fell and broke something was not an option for me. I never tried to refuse to take him back so I really don't know how that would have worked.

I was desperate to get him into a facility and was trying to check places out in the evening or at lunch, was not getting a lot accomplished. So I just went to my boss explained what I needed to do and took two days off of work. Like you, I had been missing a lot of work with him and hated to take more and I was lucky my boss was very understanding and even gave me a few tips. I did some internet research and the Department of Aging here in Tx has a listing of all nursing homes that accepts Medicaid, I called as many as I could to find out if they took Medicaid pending and made a list of the ones I felt were okay. Note, I did not do this on my days off but rather in the evening and lunch otherwise I would have probably had to have taken another day. I made a map and my first day off, I went and visited as many Medicaid accepting facilities that I could including a few that I knew did not have Medicaid Pending available, as they can put you on a waiting list. I visited 8 nursing homes that day and talked to the administrative staff at each one - explaining my story to them, they were most helpful and answered a lot of questions for me, one of the facilities that did not have a Medicaid pending bed actually made some calls for me and recommended a sister facility (this was a Sava Senior) that I eventually placed him in - one that was not on my list so it was a huge help.
But ask a lot of questions - one of the places that was close and I really liked would have crammed him into a room with 3 other people - that was something I noticed in the walk thru that they had some 4 people rooms and I had to ask to clarify that - and indeed the 4 people rooms were Medicaid pending, I did not feel that the transition from home to NH for a dementia patient would be very smooth even sharing a room but 4 in a room (a small room) was just too chaotic. So ask a lot of questions.

By the end of that very long day, I was exhausted but had chosen two that had Medicaid pending beds available, a first choice and then a second for backup and knew what they needed to start the process.

My second day, I collected the paperwork that the nursing homes needed as well as bank statements - SS info etc. (In retrospect - I should have done this the first day, as I could have just given the nursing homes the paperwork when I visited as this could have made things quicker. but as I was going back with LO to have him look at facility as well, I just took them the paperwork that day.

I needed full medical record from Primary Care Dr - along with medical record from his Neurologist (this is very helpful in getting him accepted at the NH especially if he has dementia) and record from his last ER visit. I called the Drs offices and hospital in the morning and explained to them what I needed and that I would come that afternoon to pick them up - did not take no for an answer as one of the dr's offices tried to put me off. I had printed out his bank statements for the last six months, downloaded a Medicaid application and filled it out, made copy of his DL and SS card as well as his insurance information and made a copy of his small life insurance policy, I then carried all of this to Kinko's and had 4 copies made, one for each nursing home, one to use with the Medicaid application and a spare just in case.

When I took LO to NH to visit - we only went to the first one because he was okay with that one, I was able to hand them all the paperwork needed to start the process, and a week later I was able to get him into the facility. Now this was not an easy decision and I am still wrestling with guilt - he is being pretty good but asks to come home - but he is getting physical therapy, regular bathing, his medications and has only fallen once in over two months. I know that a lot of caregivers that comment here do not like NH - and truth be told, neither do I, but I do think every situation is different, in my case - since his children would offer no help or support and with his financial situation the SNH really was the best choice for his much needed full time care and safety. I do feel better about placing him because I did the multiple visits - you would expect the more expensive homes to be the nicest, but that was not always the case and a couple of the places I got no further than the front door and I knew that it was not going to work, however, I did the tour and talked with them, well just because I was there and wanted as much information as possible in making the decision.

Now just so you know, once he is Medicaid approved - you can easily move him to another facility as Medicaid approved beds are more available than Medicaid pending.
I may move LO as the facility he is at is not as close as I would like but will leave that up to him, he is about a 25 minute drive, there is a facility about 10 minutes away so I could visit more, but he is adapting and doing pretty well so will think long and hard before moving him.

For your information, the nursing home submitted the Medicaid application on the day of his arrival - approx 8/15/14 and I just last week got the approval back, I do think that filling the form out correctly and providing them with all paperwork required at the time of submission makes it go faster.

Good luck with your Dad, I hope that this helps. I really think that waiting for a LO to fall and seriously hurt themselves before getting the proper help is a very serious flaw in the medical and insurance care of elders.

Yes, you can refuse to accept discharge. They can get very nasty about this, but you need to stand firm. sometimes they are completely helpful; I've seen both situations.

YES {Q}refuse to take him home. It is the quickest route to placement. The hospital needs to insure they are releasing him to an appropriate environment. ..For Medicaid nursing home placement must be medically necessary so the doctor needs to write orders.{EQ}


You say your his guardian. Talk with your elder affairs attorney ASAP. Find out who pays the bill. Was he sent to the hospital under the guardianship?

I would be interested in what that does regarding your financial liability

Do not sign any financial liability agreement in your name.

Not sure where you are located.In MA, most nursing homes no longer discriminate between private paying and medicaid patients; however, they do like to get those 90 days of medicare payments, which they can only seem to get when someone is discharged from a hospital with a medical order for skilled nursing care. ERs are notorious for discharging patients, especially those with dementia, because they cannot just admit them to the hospital, and are overwhelmed by the growing population. I once had to abandon a relative in an ER because I lived out of town, knew it was an accident waiting to happen, and could not care for him. I had been trying to get him services,unsuccessfully, for over three months and knew that he was in real danger. The ER doc called me several times the next day,trying to guilt trip me into taking him home. I just kept telling the doc that I could feel his pain, but could not, in good conscience, discharge him. He spent 3 days in the ER and was then admitted to the hospital. Once I was able to develop a relationship with the hospital social worker and reviewed allI had been through to get him services, she agreed that there was a gap in the system. In this case, the patient had a rare degenerative brain disease that was not well understood, was already on medicaid, but was under 60; therefore agencies like Elder Services had nothing to offer. He ended up spending about 30 days in the hospital while they helped me apply for guardianship in order to place him in a nursing home. Their system involved sending his profile out to their comprehensive list of nursing homes. Once they get three acceptances, the family must choose one. The hospital referred me to their lawyer to apply for guardianship and had prepared me to foot the the 3K fee; but fortunately, the attorney informed me that I was not responsible for this payment and that if the patient did not have means, the hospital would pay for it. I did not feel proud of abandoning my relative in the ER, or of letting the hospital pay for guardianship. However, I shudder to think of how things might have played out had he not been admitted to the hospital, and later the nursing home. I was working for very little money at the time, and trying to finance college tuition for my own children, so although I would have otherwise paid the fee for guardianship,it would have been a hardship. Hospitals are very quick to discharge people without suitable discharge plans, and often intimidate families with medical bills. Just recently,my mother's day care rightfully sent her to the ER because they thought she was having a stroke. They did the usual tests and concluded that the symptoms were caused by the antibiotics she was taking for a sinus infection. They wanted to discharge her immediately and in fact asked that she go right back to day care so that their nurses could keep an eye on her, just in she had had a TIA that didn't show up on the tests. The day care nurses, rightfully, resented the hospital's assumption that they could do this and didn't want her back until the following week. Since she can't stay alone, and the whole episode had disrupted her usual day care schedule, I was able to get her admitted into a SNH where she regularly goes for respite care. This particular discharge process should not have posed a huge problem for the hospital social worker; nevertheless, they would have been very willing to discharge her and let me pick up the pieces had the day care nurses and I not pushed back. The point I'm making here is that, with hospitals,admitting and discharging patients comes down to dollars and cents. Elderly people, especially those with dementia, are vulnerable because they often require nursing home services (medicaid) rather than skilled nursing home services (medicare). But you are not obligated to let them discharge a patient into your care if you can't take care of them, even if you are living in the same home. Nor can they make you financially responsible, even if you have POA or guardianship You must push back.

I do not agree with SWM. There are many court appointed guardians that are not required to provide care in the home. It is the job of the guardian to determine whather appropriate care is being provided in any location. If not appropriate then they are required to find the level of care necessary.

Just imagine if guardians were required to provide the care, there would not be nearly as many people working in the profession. If providing care was required since many guardians have many clients how in the world could they manage?

The guardians job is to identify appropriate placement and make it happen in collaboration with hospital social workers and other medical staff.

People, falling parents does not necessarily mean a trip to the SNF, remember they need to qualify for placement (skilled need). Baby sitting (custodial care) to prevent falls does not qualify for placement. Family members need to stop thinking that the hospital is the end all for their parent problems. Families need to start taking responsibility and begin talking with their elders ahead of time to prevent a "social dump." This means placing the family's responsibility which should have been addressed way before the multiple falling issues become more frequent on an acute care hospital. There are so many programs and resources that a family can obtain to direct them regarding placement.

It is much easier to get a SNF bed after a hospitalization than directly from home. When he falls the next time, because there will be a next time, unfortunately, call 911 for an ambulance & let the hospital admit him. The doctors taking care of him in the hospital *should* be able to see that he cannot be sent home to live by himself---and you must not give any indication that you are able to live with him & take care of him, you must stress that he lives by himself--they'll have to order that he go to a SNF. It may not be the one you want him to go to, because they do it according to available beds at the SNF's (although some places ask the family if they have any preferences, and they'll try those places first). A hospital cannot kick him out if there is nowhere to go & no one to take care of him since he is unable to live by himself. At the hospital, usually a social worker takes care of getting the evaluations, orders & other things to get a SNF bed. You only have to provide financial information after Medicare stops paying. And don't let the SNF try to dump him on you after Medicare stops paying----they're famous for that. They get their Medicare money & then don't want to keep the patient because they don't want to deal with Medicaid. It is obvious your father cannot live by himself.

Have you thought of trying to get a home health aide for him? If the doctor orders it, Medicare should pay for it. I don't know much about that. I doubt he'd get 24 hour care, though.

Louise, ditto what Veronica just said, but another big thank you for telling us all in such detail how you did it. Maybe you should write an article for AC!

Please be sure to talk to your dad about what you're planning. Don't just put him somewhere without his being able to know what's happening and why. We will all (hopefully) be old someday, and wouldn't want to be handled like a house pet that needs ridding. I understand fully when you need round-the-clock care with an elderly parent....my dad was hospitalized after living with us for 7 years with pneumonia, sepsis, and once there, he needed breathing assistance and tube-feeding. Only skilled nursing could handle him in that condition. But love your dad and be very reassuring to him every step of the way. You're under stress, but please think of the stress he's under as well.