They are sending my mom home from the rehab center and she is still too weak to walk. Any suggestions?

Karsten, TRICARE is from my understanding somewhat like Medicare in that it's the "parent" program of coverage, rather than a specific aspect or program (such as A&A). A friend who was a career Navy man had TRICARE in lieu of MEDICARE.

also as RayLin said, apply for Medicaid. Though that would depend on your moms financial situation. We were "lucky" in a sense that since my dad was a vet, and on hospice, he qualified for free SNF at a VA contracted SNF, and the one we ultimately picked was very nice. Too bad we didn't find that out earlier, but the social workers at the rehab and hospital didn't seem to be too informed on that.

I think you mean Aid and Attendance through the VA. benefits.va.gov/pension/aid_attendance_housebound.asp
But I don't think your dad being a vet would help your mom in this case. I could be wrong.

As Garden said, Medicare should pay for limited at home care, but mainly short visits, (checkups, baths, etc). I found that by the time you hired out for too much at home care, you would be better off, economically anyway, going to an assisted living or even SNF if needed for a while.

Amervg, contact Medicare, now, and ask about home care post rehab discharge. I've heard nothing to the effect that it no longer covers home care after discharge, unless it's a recent change. If you get through to Medicare, get the ruling or specific citation for the provision on home care. Then tell the Administrator or DON that you need to speak to someone who can and WILL script for home care.

I think the SW is wrong. Don't take her word on post rehab home care.

Also, contact TRICARE; I don't know for sure what it covers in home care, but it's worth a call.

Sorry, one more question. How do you apply for Aid & Benefit? Is that for Assisted Living or a nursing home only? Dad was a Vietnam vet and died in 2006. Thank you!!

Thank you all for your responses. Mom has Aetna and Tricare as well. We will have to find a way to pay out of pocket for home health care until we can figure out a better way to deal with this with the short notice. The rehab center social worker was, sadly, useless. Every question I asked the answer was no, or mom doesn't qualify which I find hard to believe. One step at a time :-)

My experience with Medicare is it covers 6 weeks rehab after being released from the hospital, that's it. My mom's rehab center said she'd improved miraculously and was ready to go home after 6 weeks. Dad was devastated when he realized how very needy she still was. I don't believe Medicare covers costs for in-home care.
I would start calling locally for in-home care service. She'll need bed transfers, probably shower and toilet assistance too. I believe it is common for costs to run between $20-$25 per hour. If your mom doesn't have enough saved up, then perhaps look into getting her signed onto Medicaid.
I am so very saddened that elder care in this country (US) isn't better. I believe it is due to there not being enough money in it, it is not glamorous, and nobody gets to be the hero in the end or save anyone. I feel like we are largely left on our own.

What other insurance coverage does she have? Quickly familiarize yourself with them, ask the social worker at the rehab center to contact them and see if they'll provide coverage for continued care in rehab.

Medicare will cover home care, but it's not extensive. For us, it's been a nurse a few times a week, PT and OT 3 times a week, an aide weekly (if desired) and a social worker (usually once or twice).

It's definitely not a high level of care.

Private duty could provide more care, from up to 3 - 4 hours at a time, but it's completely out of pocket and in my experience it's difficult to find a reliable agency.

The rehab staff, specifically the social worker, should have notified you more than one day before discharge. In my experience, it's typically about a week before.

I'd enlist their help, ASAP, and ask if they can help file an application for Medicaid. If not, and if you can afford an elder law attorney, do some really quick research and find one who's handled Medicaid applications and get one filed.

If worse comes to worse and for the time being you have to rely on home care, make it clear that the visits need to be spaced so that the therapists and nurse can be there when your mother needs help the most, on HER schedule, not theirs. They'll object, but don't back down.

What's your situation? Can you be there for the first visits to establish parameters?

I don't know much - but I do know your mother needs to apply for Medicaid. ASAP.
HomeHealthCare can assist you in many ways - ask mom's physician to order HomeHealth right away too.