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I've been trying to get my dad into a SNF since July. It's just been a lot of red tape and I've had to get guardianship (not cheap). The first SNF we were working with decided they didn't want to take him (after weeks of working with them) and basically blew me off, saying they didn't have a bed. I found another and have been working to get his medical eligibility from the doctor, but the doctor is apparently not sending the SNF what they need and so I've been acting as intermediary, trying to get what the SNF needs from the doctor. It's ridiculous that I need to do all this. The doctor agrees he needs to go, but there's no communication between the SNF and the doctor!

My dad fell twice over the weekend and I took him to the doctor this morning and practically BEGGED him to complete an evaluation form and send it to the SNF (which he agreed to do). The doctor said if he falls again to call an ambulance and have him taken to the ER and then refuse to allow him to be discharged to me - basically I tell them he needs to go to a SNF and there's no one to look after him of he is discharged. He said if they try to guilt me into taking him home, I have to refuse! I've heard this before, but since I have POA and Guardianship, can the hospital force me to take him? I've been practically living in his home for a couple of months while waiting for a bed in a SNF to open up but it can't go on - this isn't my home. My work is suffering as I'm constantly dealing with my dad. I know that this is how most people get into SNFs - 3 days inpatient hospital stay then 20 days Medicare then transition to Medicaid, but can I really refuse to bring him home and insist they keep him and then transition him to a SNF?

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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.
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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
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Yes, you can refuse to have him discharged to you. Ask the nurse for a social worker. A social worker is very helpful in this situation and can usually find a bed easier than you would be able to.
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Do as his physician suggested.
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And let us know what happens; I'm so sorry you're going through this stressful time.
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Yes, you can and should 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. Simply tell them he needs more assistance than you are able to provide. For Medicaid nursing home placement must be medically necessary so the doctor needs to write orders.
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I was able to get my husband into a Nursing Home by requesting he get rehab. He was very unstable after a fall and a concussion. I had him in the NH for three weeks. He did get better and I brought him home. I realize you want to have him admitted permanently. Usually they go from Rehab straight to NH daily living.
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All of the above information is true so follow the advice, As said there will be a lot of pressure put on you but stand firm. They can not put Dad in an ambulance and dump him on the door step. sounds as though Dad does not have assets as you already mentioned Medicaid. you do not have to contribute to his care but all of his assets including house vehicle etc will be seized. So if there are family mementos remove them now because the house will be padlocked. Not a pleaseant process but you have to do what you have to do. Blessings.
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MY understanding of the Medicaid recovery process is that they don't exactly "seize" the house--at least not while your dad is alive. But they will require that it be sold afterwards to recoup monies spent by Medicaid on his care, which only seems fair.
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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.
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Sorry about your situation. I think that I might be in your same boat. Both of my parents are 89 and refuse needed help. Know that the next shoe is going to drop soon. Believe that NH are telling you that they don't have a bed is because they wnat at least 2 years of private pay before they except a person on medicaid . They will not tell you this but it is true. If you have POA see about liquidating assets to pay 2 years and all of a sudden a NHF Bed will be open. In NJ a good NH is about $15,000 dollars a month. I know sad and scary. Know you are overwhelmed. Wish I could help but have trouble with following and doing things myself
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I've never heard of a house being padlocked (unless the applicant wasn't cooperating), but you will need to sell the house. Otherwise they will just refuse coverage. You can take any monies he has and buy him things that pertain to his well being only. Like new clothes, a coat, shoes, a new pair of glasses etc... Just save the receipts.
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This happened to my father. he fell 2 times within 24 hours, my mother called 911, he was checked out-no broken bones, when they said he was okay, i said he could NOT come home. my mother can no longer help him due to her arthritis and with his dementia, it was getting harder to care for him, let alone there was no way she would be able to help him in/out of bed. I am POA so they had pysc dr come in, yes he needs 24/7 care (uh yeah), so they kept him for 3 days but due to him not needing anything special medicare did not pay. so he was sent to NH, did therapy, but we also contacted an ELDER ATTORNEY who is helping us to get things in order for the pay down, then to apply for medicaid. We haven't got his bill yet, and it will come out of their money, but it is worth saving my brother/me/mom the hassle of trying to figure things out. And yes, you can refuse to have your father sent home, you just can't do it anymore for your own health sake, and he will get better/timely care in a home. even though we don't want to see our parents/spouse there, its better than killing yourself......so what good what it do your parent/spouse then......good luck and find a good elder attorney that deals with only this stuff.
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My mother fell and got a compression fracture. She was sent to the ER. Unbeknownst to me, she was released to go home which was the wrong thing to do. Actually they suggested admitting her to the hospital or dismissal to her home and I did not realize that she would not be capable of caring for herself in the condition she was in. Two days later she fell again and back to the ER she went. Fortunately this time the social worker worked with me to get her into a rehab facility that her Medicare would pay for.

Follow suggestions here to get your father into a rehab facility as it will make the world of difference in his recovery. Now my mother is back in her apartment and is receiving outside home care services. She actually needed the services long before her actual fall as she was destined to fall eventually what with her instability issues.
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Thanks for all the input! He has not assets, is upside down on his house, and brings in ~$1600/month so I end up supplementing a lot of his expenses. I've got the Medicaid app ready to go - there's nothing to spend down and I've collected his financial records for the past 5 years. Anyway, I guess I'm wondering if he had a fall, but it isn't deemed serious, how do I get the ER to admit him for the 3 days? It sounds like a couple of people have dealt with this so . . . I should insist he's not safe, needs observation or rehab, can't come back to an unsafe environment? If there's no real medical reason for him to be admitted that's going to be tough. I know hospitals don't like to admit people on medicaid anyway. I guess this is why they try to guilt you into taking the person home. I'm kicking myself for not going this route in April when he had a COPD exacerbation and ended up in the ER. They sent him home on hospice! Still, there is a hospitalist there we've now seen twice and I think he likes me (not like that) so maybe I can sweet-talk him! Isn't it awful though? I don't WANT him to fall again, but I need him to so I can get him placed. It's utterly ridiculous. I've been trying to go through all the right channels and am getting nowhere. I'm trying to keep him safe, but have to have him fall so I can get him to a safe place.
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Pyrr- I got my mom into SNF NH from IL. Bypassed AL completely. Was able to do this by having the medical director of the NH she was going into become her doc. The group he was in at the time were all geriatricians who were medical directors of several NH. They know how to do the medcal file that will work to establish skilled needed. If his current doc just won't get you the paperwork, perhaps look into doing it this way.

For mom, it was about 6 mos of every 4 -6 weeks of appointments, and the one she had a 10%+ weight loss & bad h&h Doc wrote the orders for skilled nursing needed. It sounds like your dad already presents with enough critical issues, that skilled required orders can be written on the first doctors visit.

All of this is so emotionally difficult and the paperwork maddening.
Sometimes I can understand why family has a Blanche Hudson moment.
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Here's a question for all:
Since she has POA and Guardianship, can she sell his house, thus forcing him to move somewhere else?

I don't know if this is a good idea, necessarily, but once my mother's house was sold, she stopped thinking about moving back home, alone, and she really could no longer live alone, so it was only an option in her own mind.

I'm just throwing this out there...
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Two things we learned with my mom....make sure they have a diagnosis on record, that he is admitted in-patient and not under observation. We tried to refuse discharge when she'd been classified as under observation and were unable to challenge the discharge plus it affects what medicare pays.
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Geo - I think the stumbling block is that in order to get into a NH you have to have medical orders of some sort. We can get them out of their home, find the NH and do the paperwork for admission BUT they have to have MD orders to get in. For those coming to the NH from being in a hospital, they usually are discharged to a SNF/NH for "rehab" from their hospitalization (hospital stay paid by Medicare). Usually this seems to be a from a fall & the broken hip, knee, whatever. I'd imagine that the vast majority get into a NH through this route. Then once in the NH, they aren't able to do the rehab (which is paid by Medicare) so after the 21 day "rehab" benefit, they end up staying in NH and either family applies for Medicaid or does the spend-down by private pay or has LTC that will pay for a while.

Now there are very expensive all private pay medically supervised facilities, that will take residents without a skilled nursing orders done. Maybe the sort of place that the very wealthy, like a Sunny Von Bulow, ended up in that cost 20 - 40K a month. If family has the $$$, they can get their family member moved in.

But for the rest of us, the NH needs medical orders done. Pyrr's dad has no real $ anymore, he will need to apply for Medicaid to pay for his NH stay. Medicaid has 2 tracks to qualifying them to pay for care. A financial track - which family has to do to show that the elder is now impoverished with about 2K in non exempt assets & 2 K in monthly income and a 5 year lookback. And ALSO there is a medical track - for my mom the state sent a RN team to the NH to review mom's chart to make sure NH was medically necessary (my mom moved to NH from IL no hospital stay, no AL). Mom actually had a glitch in her chart - this even though her MD was the medical director of the NH!! There is always something!. The intake staff did not transfer all mom's medications to her new NH chart, they just noted the Rx she brought with her. Now that one was a pretty simple fix. But mom - who has Lewy Body Dementia - seemed back then pretty cognitive & competent. So she needed to have something in her chart for a "co-mobidity", so they added .81 of aspirin for CHD and changed the delivery of her Exelon, so she was good for skilled nursing needed.

Most of us fixate on the financial for Medicaid as that is what we have to deal with, but the medically necessary is just as important if your state sends out a medical evaluation team, they can find them not medically necessary, so Medicaid will not pay.
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A friend of mine was in the ER a few weeks ago, kept for overnight observation, he did not have insurance. The hospital prepared the Medicaid application on the spot and it was approved the first of August, before the hospital admit. So, if there is a medical reason it is possible to have Medicaid in place retroactivly.
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Pyrrhe, what state are you in? Are you wanting SNF to accept him as a medicaid pending patient or are you planning to pay for private care for three months?
I recently placed LO in SNF in Texas without having to break the bank and I refused to wait until he fell and did serious damage to himself, so perhaps I can give you some advice, but it would be specific to Medicaid Pending.
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Agreed Igloo - the first NH i was working with actually said he might not meet medical eligibility for Medicaid so I looked it up and figured he did and they came back and said, yes he does actually meet medical eligibility, but now we don't have a bed. In actual fact, their concern was his smoking (which they had said was ok) and the fact that he can get agitated. Basically, they didn't want him. But I had done exactly what you said - fixated on the financial without realizing he needed to meet medical eligibility! And the medical eligibility is really strict. It's not enough that you can't make your own meals or remember to eat. No, you have to need assistance actually getting the food to your mouth! (This is in the state of AL).
Anyway, he does actual meet medical eligibility and that's what the new SNF is trying to get from his family doctor. I just don't see why it's taking so long!
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Louise, I'm in AL. It's Medicaid Pending. The SNF I'm currently working with said we'll need to pay his share each month (works out to about $55/day). This is based on his gross income divided by the number of days in the month.
It's ~$6000/month for private pay and I don't have that kind of money and neither does he so there's no way we can go the private pay route.
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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.
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I tried refusing to take my mom home from er after she called squad while u was at work because she couldn't breathe (panic attack) she had the onset if deminsia and was becoming physically unable to care for herself. She was beyond my capabilities. The er told me if I refused they would have me arrested for elderly abuse and abandonment. It took me months to get her into a facility. It almost cost me my job and my marriage because of the stress I was becoming unbearable to be around. Why would the er lie to me like that?
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Oh my goodness Tina! This is what I'm afraid of too, especially since I have guardianship. I'm assuming they can't actually have someone arrested for not giving up their own life to look after an elderly parent, but it sure does seem like some will try anything! Hopefully someone else will chime in with more knowledge.
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Having guardianship of individual comes with a lot more responsibility than just having POA. I would not recommend refusing to take your father home from the hospital until you check with a lawyer or the court that granted you guardianship of your father.
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Thanks Debralee. See, this is precisely what worries me. The doctor confirmed I have guardianship and then made his recommendation regarding the next time he falls. The attorney who handled (is handling) the guardianship is actually the wife of the family doctor! I currently have temp guardianship - the hearing to finalize it is next week.
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There is a "dance" that has to be done, following procedures at the hospital. The staff must try to get you to take him home, and your part of the "dance" is to say that 1) you are unable to provide adequate care for him at home 2) his doctor believes he needs nursing care at this point and probably beyond 3) and to request firmly (just short of demanding) that the social worker find him a placement.

Hospital transfers to nursing care take priority and are easier to do. The nursing facility will love getting all the hospital paperwork transferred with him, including doctor's orders. His primary care doctor probably does not have a social worker, or staff to ensure the initial "doctor's orders" that the nursing home needs.

I would recommend that you have a doctor outside the nursing home to provide ongoing care, you can drive your dad there and sit in. I think the nursing home doctor might be more aligned with the home than with your dad.
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Ours happened just the opposite, the hospital told us that she needed to go to a SNF. You need to speak to a hospital social worker and get the help you need with paperwork to get him in, for us that was really easy it was finding a SNF with a bed available that was impossible.

Once he gets into the SNF please make sure that you check on him every day and maybe even have a camera installed in his room. My mother was only in the SNF for two weeks and she had a mysterious fall.....story has changed 4 times....she hit her head front and back and they only held ice on it, they did not take her to the hospital for 16+ hours and she died 9 days later of "Blunt force trauma to the head and brain hemorrhages." We are just sick as she was able to walk well and take care of her personal needs when she went in. I have since found out that there is an epidemic of "falls" that happen in these homes and the patient dies. No one is held responsible nor is there an inquiry as to what happened....not by the hospital or the police or anyone it seems. They are old and everyone assumes..."well it was for the best" but if beg to differ if there is abuse or neglect. Just watch him...closely!
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