Is being admitted to the hospital a requirement for long-term placement from the ER?

I guess it depends on what you mean by "placement".

In my experience, if you were hoping that they would send her to a facility for physical rehab, then yes - anytime my FIL has been admitted but discharged in fewer than 3 days (or 3 midnights) OR not even admitted (with one exception which I will talk about in a second) he has not qualified for rehab placement. He has qualified for home PT and OT however. We have been told that MEDICARE will not qualify a patient unless they have been admitted and in the hospital for at least three days/three midnights for a physical REHAB placement for OT/PT. The only time that my FIL has EVER been moved a rehab facility without a three day hospital stay first, was when he had been discharged FROM a rehab facility and within less than 24 hours he was back in the hospital for a fall, the home health nurse sent him back to the hospital via ambulance and the hospital sent him directly back to the same rehab facility.

Then you have social admits - which are for things like delirium or repeated falls - in these cases - the hospital generally feels that there are other contributing factors besides just medical issues. It might be that the home set up is no longer conducive to the patient safely ambulating or the patient has lost more mobility, lives at home alone and needs assistance or that their caregivers are outpaced by their needs. Mental problems could also be another contributing factor. And all of these things are taken into account when deciding next steps for the patient. Social admits can be anything from an unsafe mobility situation at home to a need for a psychiatric hold in order to address medication or mental health issues. And can also address the loss of a caregiver with no back up plan. In some cases a social admit can warrant placement - but not always.

When they start throwing around words like "baseline ambulatory status" and "baseline assist with ADLs" after just a few hours in the hospital I always find that interesting. I get how they can say it after weeks in rehab. And I can understand how they could look at someone like my FIL and make assumptions. But for someone like your mother who is struggling as much as she is, it doesn't sound like she is currently at her baseline and that a bit of time in rehab would have done her some good to rebuild her strength potentially if they would have given her the option.

When is she able to start PT and OT? Will she cooperate with them and do the required exercises?

For future reference - if she is genuinely unable to return home in your opinion - you need to use the words "Unsafe Discharge". That is usually enough to make them stop long enough to reassess the situation and take a longer look at things - because you have indicated that it is not safe for her to return home - at least in her current condition. It doesn't necessarily mean that she can never go home - although it can. But it does mean that they need to help find a way to improve her condition and assist you with finding solutions to help her return home.

Go to the nursing home and ask if the DON ( director of nursing), will do a home assessment. You do not have to have, but helps to do 3 midnights in hospital first. This way they do Skilled nursing care for rehabilitation and then they can stay long term. Buts it’s not free. It is expensive. But then they can help with finances, spending down, etc. see Social Servises at the nursing home.

Janine2020: Perhaps you were hoping that the ER visit (she was never admitted) would address the dementia concern. A fall and the resulting swollen hand isn't mandate for her to be transported to a managed care facility, especially since they saw that she "could stand on her feet."

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?

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.

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.

Caregiverstress is spot on with her answer

The hospital is only for emergency or urgent care until the patient is diagnosed and treated to stability condition. Once accomplished, patient is declared for discharge back home. If an unsafe discharge, do not send her alone back home. Contact a social worker to have your loved one placed in a facility for long term care.

You need to place her somewhere that you arrange and pay for. Rehab placement usually requires a hospital stay of 3 days or more, and a condition that requires and would benefit from Rehab. Rehab placement is limited to 20 or 30 days and depends on patient improvement. An ER visit and discharge after a fall do not qualify the patient for a Rehab stay.

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.

My mom’s Medicare “Advantage” plan, a step above regular Medicare, allowed her to go to rehab after two days instead of the usually-required three. Call the rehab place, your insurance, or talk to a social worker at the hospital. They will know.

Get with an elder care lawyer licensed in your State. There are many considerations here, but IMHO what you were told was not wrong. Time to plan for the next time -- there will be one if she falls often.

If she has Medicare, was admitted inpatient (not just at the ER) for 24 hr or more AND at discharge she needed other "medically required" services such as IV antibiotics for a period of several weeks, perhaps wound care or other post op medical services only a RN could provide -- there is a long list of factors that may qualify them for skilled nursing/Rehab care -- Medicare may pay for a limited number of days as long as they "continue to improve." The benefit in theory is about 100 days minus the number of days they were inpatient at the hospital; but Medicare rarely pays/covers the full 100 days (more like a few weeks, a month or until the IV antibiotics and pic line have been removed).

If your LO meets the medical requirements for a discharge to SNF/rehab post inpatient stay, then hospital social workers will help with that placement. Best to do your homework to ID high quality (not necessarily the closest) facility; ones both Medicare/Medicaid qualified AND which also has SNF or long term care/memory care beds if thinking about a permanent placement post Medicare coverage.

But the shift to a permanent placement is NOT automatic. Having the legal paperwork executed (by an attorney) before all of this including a durable financial and medical POA AND an Advanced Directive (Will or Trusts too) is key. Upon discharge from inpatient stay (if your LO needs SNF/Rehab), the next facility will have paperwork for you to sign if you have that POA (it needs to be one that gives you immediate rights to step in for your LO; NOT a POA triggered by their incapacity). That paperwork should be reviewed by the attorney. There are trip wires written into most of them (many, more than 100 pages) with questions such as will YOU be personally/financially responsible for your LO (answer NO). Will you agree to take them back if Medicare no longer pays, they cannot pay and Medicaid does NOT cover (answer NO). All to say, in a crisis and dealing with this at the time, it is easy to check all the YES boxes and agree to things you may not fully understanding, like YOU personally will pay your LO's bill. Make sure to get the paperwork before the discharge to said facility and have a lawyer advise you as to what to sign, agree to or what boxes to check OR not.

The lawyer can also help you work through what other steps are necessary if Medicaid long term coverage is likely needed to pay for the costs of the permanent placement in the nursing home (Medicare does NOT cover long term nursing care), but this is not a quick or easy pathway. First, your LO must qualify in two ways: 1) their level of care requires nursing home care (this is based on their medical needs and perhaps cognitive decline and ALDs/IADLs they can perform safely and independently -- they will be assessed, this is not just something you report as fact), and 2) they must meet your State's Medicaid income/asset limits (many are around $2K in total assets). So if assets are greater, your LO has to privately pay the nursing home until they are spent down; all assets are gone. This later part again requires you as the POA to do things like sell the house, any valuables, spend down any IRA/401K funds, sell all stocks, etc ALL ASSETS! If your LO has a spouse there are things that can be done to save resources for him; the lawyer can help w/.

If there are lots of assets, perhaps high level assistive living or a continuum of care facility (which has SNF if needed) is an option? OR perhaps home health aides can be hired to help your LO remain at home for a longer while? Finally, Adult Protective Services, can help if they are NOT safe living alone. APS/the State may need to take over as their guardian to make decisions such as a permanent nursing home placement.Good luck!

A nurse in the ER told me that if I let them know that I could not take care of her, that they would find a place for her.

Months later, after a few more ER visits, they trasferred her to a TCU/SNF for rehab, without me having to ask.

Wherever you place her, she will still fall because she will have alone time. You will also get calls about falls asking what you want to do, such as going to ER.
You might want to talk to her doctor to see if a few PT sessions might build strength, but it could also mean it is the progression of the disease.

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.

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.

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.

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.

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.

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.

To my knowledge, you don't need a doctor's permission to go into a nursing home. My mother moved into a skilled nursing facility (the wrong type of care, too) right after my dad died. She was there for seven months before I figured out she needed memory care instead, and other than the MC's nurse giving her cognition test, there was no issue with moving her there either.

If you think she needs to be in a nursing home, call one up and see what they require for admission.