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My mother's husband has been in and out of hospital (is currently in a rehab facility). My mother was taking care of him (not very well, since she is elderly). My mother fell and broke her arm in 3 places. She just had surgery with a rod put in last week. She cannot really take care of herself and the rehab place that her husband is in wants to send him home.


What can be done? He cannot take care of himself, and she cannot take care of him. I live 25 miles away (and work 2 jobs), so I can only stop by for a short time every few days. (His children will not help in any way.)

You just tell the facility where he's rehabbing about her and let them know he cannot come back home for a period of time (or never). They will help him to become self pay to stay at rehab or move to long term care facility. OR you can go with her to an elder attorney to ask for help getting into nursing home. Atty can evaluate his income and determine if he might be eligible for a medicaid bed. Atty is your best option.
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Reply to my2cents
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In my case, I had pre-arranged safe placement, but it was not available on the date of the anticipated hospital discharge. Notify the hospital Social Worker, asap, that a discharge of your loved one, to your care, would be an "Unsafe Discharge."

Appeal the hospital decision to discharge. The information to appeal a discharge decision should have been provided on the admission documentation ("Important Message from Medicare" document). The appeal has to be filed timely. In my case, I was not provided the admission documentation with this information, and I conducted online research, and filed the appeal online, the night before the discharge date. I provided a detailed explanation as to why the discharge would be unsafe. The appeal was granted and the decision to discharge on that particular date was rescinded.
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Reply to Naimka
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igloo572 Mar 3, 2025
Appeal filing can be done HOWEVER an appeal filed for a hospitalization discharge is quite different than one filed for a rehabilitation discharge.

If I’m not mistaken, the OP mother’s husband is in rehabilitation at an SNF. His hospitalization was days, if not weeks prior, so trying to appeal & reset anything associated with that paperwork is imho a non-starter. Rehab stays are dependent on his “progress” on doing whatever needed based on the rehab discharge orders he left the hospital with. If he is unable to do the rehab needed for whatever reason (he flat out won’t cooperate or he physically cannot) the therapists will notate as to this non-progress in detail in his chart which goes to Medicare / Medicare Advantage Plan in pretty much real time. No progress = discharged from rehab. Appeal filing by family/POA maybe buys 2-3 days at best as the “no sufficient progress” details are right there for the insurance appeals staff to review & review quickly and appeal denied.

Rehab is very much time limited from the get-go. So facilities are ready to do the billing switch from health insurance covered rehab stay over to private pay/LTC Medicaid filed custodial care resident.

An appeal filing while still hospitalized, imo, stands a way better chance of buying time. These would have to have the hospitalist MD to put in orders for lab work or procedures done for newish co-morbidities that appear to be happening. And until those results come back + these results evaluated + a new care plan done, they stay hospitalized. This pretty much has to be done by the hospitalist - not their old family doctor or internist unless they are the hospitalist - as the hospitalist is in charge. This appeal is driven by medical professionals rather than the family. A hospital stay is not a set time limited like rehab is; it is diagnosis driven.
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Are you POA for either?
If so you also can tell the discharge planner for BOTH parents that neither is safe at home at this time.
They both need rehab.
Mom also needs to tell anyone planning discharge that she is unable to care for him and to discharge him would be unsafe for both of them.

I would also begin the discussion with them about a move to Assisted Living so they can get the help they need daily.
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Reply to Grandma1954
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Sounds like mom would benefit from a rehab stay as well. Coach mom to repeat unsafe discharge to social worker. Stay strong, as they will push and promise the moon. It’s not enough. Objectively, it may be time to consider assisted living for them both and this is an opportunity to get that ball rolling.
Sounds like Step dad‘s kids established boundaries regarding caregiving and that is their right to live as they choose. Please don’t judge them; caregiving is life consuming and I don’t blame them one bit.
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Reply to JeanLouise
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Ask for a meeting with case manager/social services at the rehab facility. This person can help with letting you know what resources are available given the gentleman's insurance.
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Reply to Taarna
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Either he moves into assisted living facility or in-home care which is very expensive. Talk to the social worker at the hospital. You will likely get some good / helpful responses here, too.

I do not know if legally a rehab place can 'send him home,' if there isn't adequate care available for his welfare. Check into this. Do not allow the rehab facility (or hospital) intimidate you. They have rules & regulations they must follow.

Gena / Touch Matters
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Reply to TouchMatters
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There are lots of good suggestions here. Let me add one more visit the institutions you think would be good for your stepfather so that the social worker has some idea as to the type of facility you want, the cost, the amenities, etc. the social worker might recommend Places that you find unappealing for whatever reason. When I had my mom placed in a memory unit,, I was very much involved with the social worker, and I was very direct as to what facilities would be acceptable and which would not. This was time well spent because once a placement is made it is more difficult to change it plus, your family member gets acclimated to the placement and may find a change very disruptive.
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Reply to Conniejay
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cin6004: It is imperative that you state that it would be an unsafe discharge.
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Reply to Llamalover47
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Rehab facilities are only intended to be short term, so they must discharge him at some point. That does not mean that he needs to go back home!
He can be transferred to a skilled nursing home, or assisted living, depending on his level of independence.
In fact, if they both want to be together, and can manage with limited assistance, this would be an ideal time for them to consider selling their home and moving to an assisted living home.

NOW is the time to start looking at nursing homes and assisted living and schedule a tour and meeting with the admissions director. There are many different care home options and they vary in the level of support provided and quality of environment! You need to be prepared before he is discharged! Otherwise, mom will end up taking him back home!
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Reply to CaringWifeAZ
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Are you all assuming their assets are not combined? Are you assuming they don’t have assets or long term insurance etc. ? His children are not responsible for him, mom is, legally, financially and morally. Yes, see an attorney pronto but mom will be financially responsible for the bills until or if stepdad is ever able to receive Medicaid.
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Reply to Jdjn99
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Your stepfather should be placed into a facility for his care. Do not sign discharge papers since it is an unsafe discharge, so have a social worker place him. You are unavailable since you work. Do not quit any jobs.

Your mother requires either home care or recovery at a facility.
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Reply to Patathome01
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He needs to go to a nursing home.
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Reply to RetiredBrain
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cover9339 Mar 2, 2025
Short term.
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Your mother's husband needs to be placed somewhere longer term, either at his current facility or another long-term facility. There should be a Social Worker and Discharge person at the Rehab to help you look for options. Once his official rehab time is over, it will be self-pay at whatever facility you can find to take him.
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Reply to RedVanAnnie
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I’d seek legal advice and quote them legally
as others have said unsafe discharge
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Reply to Jenny10
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As others have said: UNSAFE DISCHARGE.

so where is mom right now? Is she still hospitalized? Or is she in rehab or about to herself be discharged from the hospital to rehab?

Please pls keep in mind that her husband very well could have been gaslighting the rehab/SNF staff as to all the family support he has. That his kids are so there for him & do for him yada yada type of nonsense. Ditto for you. They are taking him at his word. So that has to be shut down, you have to clearly let them know that 1. You do not live with them, 2. You are not their caregiver at all and have your own FT job, 3. He is your mother’s husband and has never been your stepfather so you have no parental relationship to him, 3. Your mothers is recovering from her own surgery and has restrictions on her ability (I bet she’s limited to a 5 lb lift at best) so she will be a caregiver (anctually make this #1). And 4. If they have any questions….. here’s the contact info for all his kids.

Personally I’d be on heighten alert to be monitoring their bank accounts and financials. If you are not a signatory n all the accounts, I’d suggest you & mom asap go down to the bank and have this done on all. Not as a Co owner to her and him but as a signatory. And then you do online access to all their accounts. All this about being proactive for future LTC Medicaid filing and knowing what their actual finances are like, so that WHEN he finds he has to private pay for him to stay at the NH, he does NOT depleted their joint holdings to all be to his advantage. Your mom does not have to herself become impoverished for him to be eligible for LTC Medicaid. NH can run 7/8K - 15K a month. A small nest egg can vaporize quickly. And you don’t want your mom to spend any $ she does not have to spend. Couples & LTC Medicaid is not straightforward and really needs an experienced atty, like a CELA level atty, to go over options and shepherd the process.

I know this sounds super negative…. but I’ve been on this forum a long time and guys like your moms hubs who are estranged from their own kids, well imho they tend to be all about themselves and will screw over the wf in an instant. Just sayin’….
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Reply to igloo572
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As said "unsafe discharge". There is no one to care for him. Maybe time to have him transferred to a Longterm care facility right from rehab. If no money Medicaid can be applied for. Mom will need to talk to an Elder Lawyer about splitting of assets, if any. Once he is on Medicaid, she remains in the home, can have a car and enough or all of their monthly income for paying bills, etc.
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Reply to JoAnn29
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Notify social workers and discharge planning at ONCE.
This is something that means that there must, at least for now, be placement in care.
They need to be warned of this.
Do NOT under any circumstances agree IN ANY WAY to take this on.
There must be placement now, temporarily or permanently.
Call rehab. Ask for the Social Worker, discharge planner, administrator and doctor and warn them of this status change and the need for placement TODAY!
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Reply to AlvaDeer
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Who is stepfather's POA?

Someone needs to speak to the discharge planner at the rehab and tell them that there is NO care available at home and that sending him there would be an "unsafe discharge". Use those words.

Do NOT sign for his discharge and do not take him to his home, or to yours.

If they send him home in a cab, call 911 and have him return to the hospital.
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Reply to BarbBrooklyn
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