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L
letdown Asked August 2019

My mom is being discharged in the morning from a Rehab facility. We've never been given medical or financial documents to review. Advice?

She is homebound requiring in-house care. Physical therapy plus dementia. What should I do? The facility is not good. In communicating nor helping.

GardenArtist Aug 2019
I'm assuming there weren't any status meetings, or discharge planning meetings?  You can handle the need for the latter by asking either the treating doctor, the administrator, the DON, or one of the nurses WHEN you can expect to meet with the Discharge Planner or Social Worker (in my experience they often handle those aspects).

That way you're letting them know that you expect some discussion before discharge.   

What arrangements existed before the rehab home visit?

Did anyone suggest home care, or ask if you preferred a certain agency for that, or for rehab at home? If not, they're sadly lacking in their duties. Those issues should have been addressed 2 - 3 days prior to the planned discharge.

If you get flack and no cooperation, and have to get tough, stand your ground, and be firm.  Communication levels and channels can very by whether or not the perception exists that the family is actively involved.   Let them know you're a hands-on person and expect home care to be addressed before she's discharged.

In the meantime, do you have a home care agency identified?  Do you need transportation to return home?

What arrangements existed before the rehab stay?

I also support the advice already given; it's good advice.
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Further thoughts:   didn't you receive an admission packet with your copy of all the documents someone (you or your mother) signed?  If not, you should have.  

One rehab facility (that deteriorated so much I dropped them after having gone there several times) pulled that with me that last time we were there, advising that they didn't have to provide the patient with copies.  I told them it was Federal law and if they didn't know the specific citation I'd look it up for them.  

I've never been given medical documents from a rehab facility; they provide summaries though, and you should be given copies of those.   When was discharged from the hospital, I always asked for a copy of the records being delivered/sent to the rehab facility.    And I usually had to correct them; that hospital made mistakes in the records. 

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AlvaDeer Aug 2019
Whomever is the POA for Health/Financial, or both should call the facility and should ask about "discharge planning",and request a meeting. This should have been done when Mom was entered into the facility. The person who is POA or who has any control of anything whatsoever goes to the office to do the admission papers. Then they are the one called about plan of care meetings, and discharge planning. These things are done pretty by state law state by state. Call now. Ask to meet with Discharge planner. Say that discharge without a discharge plan constitutes and "Unsafe Discharge". Use just those words.

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CTTN55 Aug 2019
If they know she lives with you (from your profile, you've noted that she does), she is going to be your problem as quickly as they can push her out the door.

If she's in rehab following a hospitalization, what was that for? Is she in a weaker state than she was prior to the hospitalization? What kind of care did you do for her then, and what are you going to be expected to do for her now? These are very important questions, and the time to ask is before she gets released, not after. As Ahmjoy noted, get all of your questions answered in writing before you sign anything.

Ahmijoy Aug 2019
Do not sign any discharge papers or make any transportation home arrangements until you have spoken with the facility’s discharge planner or social worker. You need to know whether she is eligible for home therapy, home health care, whether she is eligible for home Durable medical equipment, what her prognosis and diagnoses is, you need all this IN WRITING.

MAKE them communicate with you! Do not let them blow you off. Call every fifteen minutes if you need to until you get an answer. Once she is discharged, they are no longer responsible for her and you’re sunk.

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