My 91-year old mother is being released from a rehab hospital tomorrow. After 2 and 1/2 weeks of rehab and 5 days of hospitalization before that, she really isn't any stronger functionally. Her symptoms initially appeared to be a stroke, although the CT scan found no evidence of that. As I understand it, she has blockages in her brain and her brain is shrinking. She has dementia (no memory; lives very much "in the now"), she eats & drinks very little (ongoing battles with UTIs and dehydration), and she is incontinent much of the time. She can still walk with assistance and can transfer from chair to bed with the help of one aid and a PT belt.
The rehab doctors recommend that we return Mother to her apartment which is nearby our home. They believe she will have a better quality of life there than in a skilled nursing facility. My mother is very sweet, compliant, and really isn't any trouble other than assisting her with dressing/body functions/meals, etc. She happily sits in her recliner with her cat in her lap, reading or watching TV. She still has a sense of humor; she just has no memory and is confused much of the time.
I have no delusions about Mother getting better, but I hope that we are able to keep her out of the hospital so that she is able to eventually die at home. Mother has limited financial resources, but there is money enough for a home care person in the daytime (at least for a year or so), and I or my husband will stay with her at night.
Here are some of my questions:
The rehab doctor will send us home with some temporary home health care. Are there medical services that will come to her apartment to check for dehydration and UTIs? How do I locate those?
Mother has no terminal diagnosis, although I suspect she is moving into a "failure to thrive" situation. Can her regular primary care physician who is most familiar with her medical history make that diagnosis? Will that diagnosis enable us to get hospice assistance?
Are there other questions I need to be asking or other issues I need to be considering? I'm new to this forum, but I've been poring over it for information on handling incontinence, etc.
Thanks so much for any help you an give me. Blessings on all of you!
Thanks for the insights on Medicaid. This is helpful!
Before discharge ask the dr to write an order for in home physical or occupational (or even speech if applicable) therapy if you think she would benefit from that (the quality of in home therapists vary but if you get a good one willing to work the patient can benefit). Also ask for an order for in home nurse visits covered by Medicare, who can monitor patient with visits. Look into what in home dr visits are available, like a mobile podiatrist, dermatologist. some communities even have drs that make house calls covered under medicare. Does she need a hospital bed which can help with safety with rails and suport while sitting up in bed or elevating legs. would she know how to use an emergency alert button (even if never left alone, you never know when it might be needed. I had an aide who passed out on a couch. If on medicaid incontinency supplies could possibly be covered, Medicare would also cover a bedside commode (which also could be used to elevate the toilet and provide handles to assist in getting up.l possibly. Make sure the bathroom is safe with a bath seat, grab bar, etc. If she has to get to appt with an aide, you could also look into your community and medicaid programs for transportation programs for disabled and elderly.