Mom has dementia, is on Medicaid and is in a nursing facility post knee surgery getting rehab. Should she stay there after rehab in LTC?

Hi everyone. Thanks for your answers. I have read them carefully.

I contacted the Social Worker at the facility -and asked to speak with her next week. I know my mom will be in the facility for a little while longer (she's got a 6 week regimen of IV antibiotics along with rehab, so we have a little time.) and she's only been there a little over a week. She is doing well with PT. She is still kind of shaky walking with a walker. She has to take her medication daily and forgets to do so correctly which has caused episodes of increased confusion, etc. She also has overall physical/mobility limitations due to arthritis and can't do things unassisted - like take a bath. She also can't always remember how to do daily activities - like use the stove. When my dad went to the hospital, she was afraid to sleep at home alone, didn't sleep, and had her first episode of serious confusion/wandering in the hall of her apartment building where someone found her. Since then, someone stayed with her overnight and she started getting sleep again, which regulated her. But post surgery, she seems to have more episodes of being unclear about where she is. So now, I am trying to figure out how to best honor her wishes as her POA, since she doesn't feel able to stay at the apartment we rented for her anymore.

I believe that she is 'community medicaid' and I am pretty sure her doctor would agree that she needs 24/7 care. We'll see how it goes with the social worker - so far we've only been speaking with her case manager. Thanks for the advice, everyone.

I had the same issue. My mom was in an assisted living facility and doing rather well but she fell and broke her hip. She came through the surgery ok but due to her osteoporosis, her hip joint never healed. So she is in a wheelchair all the time now. There was no way for her to return to her assisted living apartment and her dementia was getting worse so since the rehab is connected to a long term facility, I would take her for walks over to the long term care area. I observed a lot and felt the care the residents were receiving was very good so I made arrangements to get her a room there and keep her there. After being in rehab for two months, she forgot about her apartment anyway and so it was an easier transition. I am very relieved that she is being taken care of.

Does your mother live with you or does she live in her own home?

Whatever you do, do not allow the discharge team to cajole you into becoming her primary caregiver or organizing her care. You are not her nurse. Your mother's needs are only going to increase and, at some point, she may need 24/7 care.

No one can care for someone 24/7 without it taking a huge personal toll. Even babies don't need 24/7 care and grow out of needing feedings every 2-3 hours. Unlike with babies, there is no end in sight - except death - in caring for someone with dementia. And many caregivers die before those for whom they are caring.

Anyone who tells you that caring for an old person with dementia is like caring for a baby is delusional. Talk to the social worker sooner rather than later.

After a long search, a friend of mine found a religious group that ran a little nursing home. They had maybe two dozen residents or so and accepted Medicaid. The place was simple, clean, and the staff was friendly. She placed her older sister with them after the money from the sale of her sister's home was spent and she no longer could afford the nice nursing home. Cast a wider net if you have to. You may be surprised at what's available outside San Francisco, which is outrageously expensive.

Does she need Skilled Nursing that the Nursing Home/Rehab provides? If no then most likely she would not be able to remain. Memory Care is another thing as is Assisted Living.
Senior Housing might be an option for her at this point if she can live on her own. Or if she can not live alone then the options would be Assisted Living or Memory Care if her dementia is at that point.
Contacting a Social Worker where she is now might be a big help an Elder Care Attorney is another option for you

I’m trying to figure out why she was given the ok by dr to have surgery when she was in cognitive decline. Dementia patients don’t cooperate with physical therapy. Long term stay at SNF sounds like best idea. Knee surgery is especially difficult even for patients who are physically and mentally fit. The dr who approved this should be ashamed of himself but he obviously has no conscience. Dementia patients also start falling so chances are the new knee will need to be replaced again. Too bad you didn’t research or get more opinions about this unnecessary knee surgery. Hugs 🤗

So CA does have some very particular programs and rules when it comes to elder care and Medicaid (medi-cal?) which is not a bad thing because I think there are opportunities that don't exist everywhere. But I am not familiar with CA specifically so can't advise on that, however I would think that the fact she is already on Medicaid takes care of a lot of the leg work and uncertainty so it shouldn't be too hard to find out what is available to her. Next I would urge you to be up front with the Rehab facility sooner rather than later, she is already there correct? Just because they have a place for her as a short term knee rehab patient doesn't mean they have a place for her on a more permanent basis, it doesn't mean they don't but it probably takes some planning and the way insurance Medicare/Medicaid in this case covers the two types of care and placements is different too so her current status there doesn't necessarily mean she will qualify to stay. Talking to them about this possibility now gives everyone a chance to investigate, plan and prepare for the barriers and options. Let them know what her current living situation is and what you can and can't provide moving forward, maybe they should or can be evaluating her for things they wouldn't normally given her current reason for being there and their expectation that she was whole coming into the knee surgery and the goal is to return her to that place.

There is nothing wrong with recognizing that a change either needs or will soon need to be made in her living/care situation and that this might be the best time to make it. While you might not have made it this quickly has she not needed the knee surgery, you are where you are and as we see on this forum everyday change in living situation can be very hard on our elder LO's and the fewer changes the better for them and for their caregivers. Adjusting to this hospital/rehab/facility residence and then back to home and back to a facility in the next 6 mos, year or even 2 could be much harder on her than making some form of her current surroundings (a care facility) long term, particularly if she is able to stay on the same campus at the same care facility since you (and hopefully she) seem to like it and it's familiar to her.

Have her evaluated while in rehab. Hopefully, there is a LTC connected to the rehab. You can have her tansferred over. This would be the time to do it.

If she is not safe at home
If you can not safely care for her (and this is your safety as well as hers)
You should discuss the options with the Social Worker.
There are things that may delay her getting accepted where she is now, are there beds available? Is this particular facility a "good fit" for her?
Now is the best time so the Social Worker can do his or her job and get your Mom to a place where she will be comfortable and safe. Does she need skilled nursing like she would get in a Nursing Home or does she need Memory Care at this point?

Anita, if the current facility has rehab & also is a NH and has an open LTC Medicaid bed for her, id really really suggest that if the NH will transition her in as “Medicaid Pending”, she stays there.

Her being in rehab places her in the window of opportunity to transition to LTC & she will have the fat medical chart to support that it’s needed and done for continuity of skilled nursing care. You want to stress that for her safety and security she would need oversight and that is NOT something you can provide, and imho you want to start dropping these points now. Really ask your NP friend on this, perhaps role play with her how to answer questions that may come at you.

also regarding the “window of opportunity”, there were a couple of posts last year that for CA LTC Medicaid program, aka Medi-Cal, the elder had to, yeah had to, go the route of coming into a facility via a post hospitalization rehab placement. Which is exactly what your mom is. The moving into a SNF/NH coming from home or IL or AL, in & of itself would not be enough to get past the initial medical “at need” requirement of LTC Medicaid. They had to be there post hospitalization as there is the documentation to show in detail with various ICD-10 codes as to what care needed. Also both the hospitalization and rehab are being paid by Medicare with her community based Medicaid enrollment paying any secondary costs. Medicare pays like double or triple the day rate for rehab (verses LTC Medicaid), so right now the place is beyond happy to have your mom there. Now she will need to apply for LTC Medicaid (it’s a different program within the huge overall Medicaid budget for your state). But if she’s already cleared community based Medicaid, her eligibility probably should not be a huge an issue as her financial “at need” documentation is in CA system. Still some paperwork to be done but I’d guess her LTC application is fast tracked for approval.

Keep in mind that right now as she is on Medicare benefit, the first 20/21 days of rehab are 100% paid by Medicare. As such she has no copay due to the NH/rehab. Her monthly SS $ or other income is still hers to keep but she really should not have over 2k as an end of the month balance. If she does for LTC Medicaid it will mean she has to do a spend down to the 2k max of assets for an individual (for how most states run LTC Medicaid). If she’s still “progressing” in rehab, after day 20/21, then it’s 80% Medicare & remainder 20% should be paid by her community based Medicaid. The 20% is fixed rate, abt $185 day.

But once out of rehab & onto LTC Medicaid bed, she MUST do a copay or her SOC (share of cost) of basically all her monthly income to the NH starting the day she’s butt in bed for LTC Medicaid.

You need to pay attention to the math....
Say your mom has a small set aside of $, like 1K either in a savings account or a checking account for emergencies. & mom gets $1200 a mo SS. On 4/20 she moves out of rehab as no longer “progressing” & onto LTC. She has to do a copay of last 10 days @$ 40 of April SS$ to the NH = $ 400.00. You as her dpoa kinda need to make sure that the copay is paid. The $800 left over from April SS$ can go into her bank accounts that has the 1k, so she ends her month at $1800 in assets and under the 2k max allowed for LTC Medicaid. If your mom might be over the 2k EOM, find things to spend down on now for her. What depends on how much $; it it’s way over 2k, probably a preneed funeral & Burial is simplest. FH will know what to do & that’s Medicaid compliant. If it’s just a few hundred over, buy extra eyeglasses, hearing aids, shoes and clothing that is easy to put on & can take heavy duty laundry machines.

I’d be concerned that if you take her home & like 4 mos from now, her care needs are beyond your ability, that she cannot get into a NH if the standard for being “at need” is based on continuity of care via facilities (hospital to rehab to LTC) route.

Your mother's safety and quality if life is paramount. Have her thoroughly evaluated to see where she is with dementia. She can also get the meds to help her. My mother has cerebral atropy which has progressed quickly. But we have her medicaid living choices assisted living and she's doing very well, happy, eating and sleeping well. And she's on very minimum meds. It's difficult to make tough decisions for our parents, but safety and quality of life for her is so important.
Blessings