My grandma is going to be discharged tomorrow from rehab. I have been calling all week and finally got to speak to someone. I spoke to the social worker and physical therapist. She never received a letter from Medicare or rehab with the discharge date.
I was getting different information from everyone. Some were saying she can transfer (from the bed to a chair). I don't think she can walk. Before her hospitialization, she was able to walk around the house and walk 200 feet or more to the car. She was going to multiple appointments. I asked for the reason for discharge and they are saying she plateaued or that is the best they can get her. The physical therapist didn't know she was able to do so much prior to the hospitalization. They just assumed she wasn't very mobile. The social worker and physical therapist put it in her notes and will discuss it.
They said I can appeal and it will likely keep her there for 3 more days. Otherwise, they are suggesting we apply for long term care. We just need her to be able to be somewhat mobile before taking her home. It is also a bad time to be taking her out. We are afraid that she will be sent right back to the hospital. We don't want her to be exposed to the corona virus.
They did this before around 5 years ago. She wasn't mobile and the doctor at the hospital was saying she needs long term care. My mom wasn't able to care for her any longer since she was being brought back to the hospital so much. We set up home care. It turned out to be a reaction to the lasix she was taking. She gets side effects if she takes it too long. It only took 2 days before she was walking down the street again. She never went back to the hospital again until recently.
Do you have any suggestions on what to add to the appeal? I'm hoping the physical therapist changes her notes after our talk today. I'm also thinking about calling the doctor for the rehab and notifying him of prior lasix issues. I'm not sure if she is still on it or not.
I've never received letters from Medicare or anyone at a rehab facility. In my experience it's done either at the care conference or by word of mouth when someone stops by the room.
You can ask for a phone call with the rehab doctor to get her perspective. I've found though that typically the rehab staff are the ones most informed as to capabilities.
And the Social Worker should have spoken with you or other family representative about home care, which would continue her rehab at home. That absolutely needs to happen before dismissal takes place.
If you do get an extension, what are the plans then? Stay there, perhaps on private pay? (How long has Grandma been at the rehab facility?) Do you have any backup plans for her return home, or wherever she's been living?
It does sound as though a long term care placement might be helpful, but I would first focus on getting in home health care with a company (preferably of your choice) while working on short and long term care.
If you do get an extension, start researching and calling home health care companies to get that set up so it can be started the day of or after she returns home.