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I am trying to seek placement for my mom who has dementia and is also a fall risk after falling multiple times over the past few weeks.



Last night she had another fall
and her hand was so swollen that we called the paramedics.



She got checked out in the ER with X-rays, lab/urine tests, EKG, MRI etc.



The test results turned out "ok" and she has a swollen hand. She was sent home and offered home health with physical therapy along with a phone number for a senior resource contact to assist with expediting an "Assisted Living Waiver Program" application (we are in CA). Not sure that physical therapy will be able to help with her muscle weakness at this point - she is hunched over and can hardly walk without assistance and has difficulty transferring from a wheelchair into the car.



The hospital's "case management" said they could not assist with placing her since she does not meet the requirements for "short term rehab SNF placement" and is "baseline assist with ADLs" and "baseline ambulatory status" despite the safety concerns we expressed with her falling at home, not being able to lift her etc- they considered her to be ambulatory since she "could stand on her feet."



Does this sound right with the hospital not being able to place her or were we misinformed?!

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You can place someone with dementia in a memory care or nursing facility of your choice anytime you want.
I think you're getting confused with someone being placed in rehab and then being moved on to a facility.
You can also do what is called a ER dump. That is where someone is brought into the ER, and then family says that this person is not safe to return home, as there is no one there to care for them, and that you WILL NOT be responsible for them.
The hospital social worker will then have to look into having the person placed.
So you have the option of now looking at different facilities in moms area to place her in, or next time she goes to the ER, you refuse to take her home and let them find a place for her.
I wish you well.
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Are you asking if you can use a hospital admittance as the “trigger” to get your mother placed in memory care? Many, many people do this when they have loved ones who refuse to go into care. I spoke to a social worker and a memory care center director about how to get my father placed when it comes to that, as I know he will fight tooth and nail to stay in his home. I was told that my opportunity will come if he is ever admitted to the ER. And if I need to expedite this trip to the ER I can get him into his primary care doctor who will “admit him for tests”, or on a psyc hold. Or even go as far as to call APS for wellness checks and tell them he is unsafe. At that point I have to say he is an at risk senior living alone with Alzheimer’s and there is no one to take care of him. And then hold firm when they say they will send him home with aids, as they most likely won’t. I have a couple places picked out already that are really nice and they will access his level of care needed, and then the doctor will fill out the forms and the social worker and the director of the facility will get the placement set. That way, as the social worker said, we are the bad guys, it’s the doctors taking him from his home, not his daughter.

I missed my opportunity to do this a year ago when he was newly diagnosed and was acting so aggressive that a friend thought he was going to have a stroke (he was screaming and yelling and advancing on her) so she called 911. He was so worked up they had him in a straight jacket on a 50/51 hold. His dx was so new and he was still mostly cogent that we were all at a loss as to what to do and felt it was too early to have him placed, so after they calmed him down he went home. He says he has no memory of that incident. If something like that happened again, this time I would use it get him placed.

So in short, yes, it’s possible to use a trip to the hospital to get your mother placed, but you are going to have to say some things that are hard and will make you feel guilty, like you can’t take care of her and she she has nobody who can. But it’s for her own good.
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Keephope Feb 2023
Went through the same situation with my father-in-law. Thank you for your insightful answer.
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The rule is 3 midnights in hospital to qualify for SNF aka rehab.

They can not place her without that criteria being met per Medicare rules.

I would request a needs assessment before you file for Medicaid because she may not qualify for assisted living facility and you want the right public assistance in place, LTC and waiver are two different assistance programs, and you want her in the right level of care.
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PatsyN Feb 2023
Just a point here: just because you're actually in the hospital doesn't mean you're actually admitted. My mom was in a hallway/curtained ER room for 3 days. She was not considered admitted--even though we'd called ambulance for her on her doctor's insistence. I'm sure it had to do with insurance reimbursement. I can't remember the specifics of what was "wrong" with her but this was at least in part for tests like EKG, blood work. That's how doctor's office does it now. There was no particular "emergency."
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While rehab may not help a patient improve, it may keep a patient from getting worse or slow down the progress. Too many times providers fail to prescribe or continue PT/OT based on they are not expected to improve. Some patients can still continue to receive the services on the basis of this legal case.

https://www.cms.gov/Center/Special-Topic/Jimmo-Settlement/FAQs

I have found many hospitals and large clinics often cut off therapy after so many visits according to the old rules possibly due to heavy case loads or it may require more documentation on their part. Smaller facilities are often more willing to document as needed to continue serving their patients. When a provider gives you a prescription for PT/OT you do not have to take it to the one they are connected to or whose form the prescription is written on. More and more it is being proven that exercise (even very limited exercise) is one of the best medicines for many issues.
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tothebeach23 Feb 2023
Thank you for this. A lot of us need this information.
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My mom has dementia and she was in and out of the hospital a lot from breathing problems and I could not get my family doctor to help. So with being in and out of the hospital so much the doctors in the hospital said she had to go to the nursing home. I had to pick out the nursing home and they did the rest. Plus I had to sign because I an her power of attorney. But the doctors at the hospital told her she could not be alone. It was rough at first because she didn’t want to stay but they keep testing her and she’s not capable of being by herself . I would say the hospital is your best option for her to be tested and they will talk to you what your options are unless you have a really good family doctor that will back you on her being placed. I’m in Ohio.
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No, the hospital does NOT have to admit someone to help with placement elsewhere. My father was not admitted as he had no medical reason to be, but they held him as a social admit, or under observation until they could find a nursing home. My father was falling all the time (due to PD) at home as well, and I told the team at the hospital that and that I couldn't be there to watch him all the time. They understood he would be unsafe going back home so they held him and found a long term care facility. You need to tell the SW at the hospital or contact a State SW and emphasize that your mom is unsafe at home and you cannot guarantee her safety. Or the next time she goes to the hospital you refuse to take her home or contact a state SW for assistance.
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No it’s not a requirement but I also do not recommend you place her in care recommended by the hospital. I can only tell you about my experience. In my case the hospital could not easily find a bed for her so the found one in the worst place ever ( I did not know at the time) She actually got worse. They played financial games to keep her longer and lied about care options. You do have choices and I recommend you start looking sooner than later. The good places are full but you can get on a waiting list. Do your research.
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Speak with her PCP and advise re safety concerns; get second opinion on placement options. You can also contact a local hospice of your choice, speak with the Clinical Supervisor ( RN) , explain your and your mother's situation; the hospice will be glad to speak with you and you can go from there ; it sounds like potentially you could ask your mother's PCP for a referral to hospice for " hospice evaluation of patient for hospice admit appropriateness". If you request this of the physician they must make the referral to hospice upon your request. Hospice can then come to the home, evaluate your mother, speak further with you and your mother about hospice and, go from there depending on what their hospice evaluation shows.
Hospice is about living and quality of life for both the patient and family and, can be potentially very helpful in the home and/ or further placement considerations both now and down the road.
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Talk to the doctor. It is easier to go from hospital to rehab or NH, but it's not impossible to have a doctor assist to getting her from home to rehab/NH either. Not really sure she needs to go to AL because she will still be mostly on her own with very limited care from staff. AL means just that - she needs minimal assistance to live alone and that doesn't sound like your current situation. If she is as weak as you say and don't think the therapy is going to help, I would be very surprised if an AL facility will take her. The falls she has at home now will only continue if she can hardly walk or transfer well from one seat to another.

More than likely the case manager could have assisted in moving her to in patient rehab or discussed with dr going to NH from the hospital, but you might have got one that didn't want to mess with it and easier to discharged, Ambulatory might be subjective to the person deciding her abilities, but ambulate means ability to walk, not just standing in one place.

In the mean time, while waiting on help from doctor for her placement, the therapy at home may help to get her stronger and have some professional eyes on her who will report back to her doctor. If she's not already using one, it's probably time for a walker. The rollator type have 4 wheels w/breaks and a seat if she needs to sit down. They can go a little too fast and get away from you on smooth tile or wood floors. Carpet slows them down and it does better. The therapy folks can get her moving with one of those - ask about it when they do the evaluation for her therapy needs.
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It’s not clear to me what sort of placement you were looking for or your mother’s condition. Maybe that is part of your problem. A swollen hand doesn’t sound like a rehab placement to me, and the hospital isn’t required to sign off on a voluntary, self-pay AL placement. If you were looking for Medicaid placement there is an application process to go through and I don’t suppose she would be immediately admitted unless it were an emergency situation. Does she want to go into care? Could she have persuaded the hospital staff that she was okay living alone or that she had someone taking care of her?
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