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Urgent help please! FIL Discharge from hospital and nursing home

(39 Posts)
ratbagcatbag Tue 29-Jan-13 21:19:50

Hi all

I'm really hoping someone can give me a bit of advice before I have to speak to the hospital tomorrow.

I'll try and keep it brief but will need to explain background a bit.

My FIL is 83 and lives at home with my MIL, he's been suffering falls on and off and on the 4th Nov, he fell over and broke his hip, he was admitted to hospital and had a hip replacement, five weeks in as he was slowly getting back on his feet, for some reason at 5 am one morning he got out of bed and fell, resulting in the other hip breaking. He had another replacement and was back on the ward under one to one care due to the previous fall, he was also diagnosed with dementia at this time. He was now very nervous on his feet and generally unable to walk any distances at all, just transfer himself from bed to chair. Around 5am a few weeks ago the individual on one to one observations left my FIL and he fell again, now breaking his wrist (there is a complaint in about this). He's now unable to walk, move from chair to bed and is incontinent nearly all the time, and has to be helped to do everything.

My MIL has realised as much as she wants him home she cannot watch him 24 hours a day and lives in a house with steps to each room and only an upstairs toilet (he does have a stairlift, but cannot work it on his own or get himself to it)

My SIL found a nursing home literally two mins from my MIL's house which is perfect, we assumed as FIL had a lot of savings we would not be eligible for any help and reserved him a place, and he's going to be discharged on Thurs to it. After going to the bank it turns out that most of the savings (over 40K) are in MIL's name, and FIL has approx 17k. SIL rang the hospital and explained, to be told that they hadn't assessed him for needing care home, only carers at home and it would take a while to get him reassessed, my MIL got distressed and has now gifted my FIL £10k so he can still keep the nursing home slot.

I'm now concerned that we are making a rod for our own back, and think we should force the hospital to reassess him for nursing home (which doesn't sound like it's been done) and if it delays it a couple of weeks then we just pay for the spot at the nursing home to be kept open.

So as SIL has sorted this and now realised she might have been hasty it;s left to me to sort tomorrow morning, can I actually refuse discharge until the Community Care plan is sorted and communicated to us in writing.?!?

Help anyone there are probably so many things we are missing or I'm doing wrong.

I am arranging to see solicitors and financial advisers with MIL late this week early next, I just am concerned once he's discharged it will be a lot harder to get everything we need from social services once he's already gone and freed a bed up.

Many thanks if you are still with me, I really do appreciate any advice smile

ratbagcatbag Tue 29-Jan-13 21:20:59

Sorry to confirm the second fall (with another hip replacement) occurred in hospital.

IwishIwasmoreorganised Tue 29-Jan-13 21:23:55

Sorry to hear what an awful time your FIL has had. It does sond like he needs 24 hour supervision, and that would be incredibly difficult for your MIL to maintain long - term

He'll need to be referred to a social worker for a full financial assessment in terms of funding his long term care. Do you know if he has been referred?

ratbagcatbag Tue 29-Jan-13 21:28:57

He definately has a social worker in the hospital, but she was the one today who told SIL that she'd only assessed him for home care, which then like I say panicked everyone. I guess I need to ring her at 8 am and tell her that she needs to reassess him considering his one to one 24 hour needs and see if that results in the care home option being partially funded.

IwishIwasmoreorganised Tue 29-Jan-13 21:52:10

It's the SW who will be key in funding the care - whether at home or in a nursing home.

Has there been any discharge planning meetings? You as a family, should be invited to meet with the multidisciplinary team involved in your FIL's care to discuss his current care needs and how they can best be met. If it's constant supervision, and he is more or less immobile and incontinent then that's going to be incredibly hard to manage at home. Here in Wales it's only possible to get 4 funded care calls a day, and nothing at all overnight.

ratbagcatbag Tue 29-Jan-13 21:56:21

They originally said 3 visits but not ready for leaving hospital just yet as problems above, but I think SIL has pushed since the spot at the small nursing home became available, I haven't been aware of any discharge meetings - presumably if they suggest that he can have 3/4 visits per day we can just ask for the direct payment for that (assumes worth around £10 per hour - so £30 per day - £150 per week towards nursing home) or doesn't it work like that.

I have a feeling the social worker is not going to like me tomorrow when I ask for him to be reassessed after she thought he was being discharged.

Thanks for your help by the way, I do appreciate it. smile

AnyaKnowIt Tue 29-Jan-13 22:00:24

If you want fil to go into the care home, refuse to have him back at home.

It sounds cruel but sadly its the only way

It doesn't really work like that TBH.

I would also suggest you ask them to assess him to see if he qualifies for Continuing Care/Continuing Healthcare, as it sounds like he has complex needs and he may qualify. That means the NHS would meet all the costs of his care, it is very hard to get though.

www.ageuk.org.uk/home-and-care/care-homes/ Some good info on here.
Sometimes the first few weeks after discharge to a home are seen as an assessment placement and may be funded also.

And I agree with the PP - do not accept him home to 'see how you get on' or anything like that - it will be arranged much quicker if they are trying to free up his hospital bed TBH sad and he sounds clearly unfit to be at home.

IwishIwasmoreorganised Tue 29-Jan-13 22:04:48

The team there have a duty of care to ensure that his d/c is a safe one.

He's possibly going to need a hospital bed with appropriate mattress, maybe a hoist to get him in and out and sensor pads by the bed +/- chair (if he's going to be sitting out at all), regular pad changes to maintain skin integrity (usually every 2-3 hours). What about eating and drinking - is he able to manage a normal diet and fluids and feed himself?

Even with careers coming in 3 times a day, that leaves a huge amount to do inbetween calls. Your MIL is unlikely to unable able to change his pads alone.

Here in Wales I believe that everyone gets a certain amount of free care, then anything above that is financially assessed. Some nursing home fees can be fully covered by social services, others charge more and the pt or their family top up the fees.

Don't worry about being unpopular on the ward, your concern is for your FIL and MIL. Do you know if the NH are able to keep the bed while things are worked out, you might be able to pay a retainer fee.

ratbagcatbag Tue 29-Jan-13 22:07:40

We want him home, but all that will happen is my MIL who is in need of a hip replacement herself and suffering early signs of dementia and is 79 will struggle and then they will both be in a mess, at least the nursing home we have got him in is less than 100m from her front door.

Ok plan of attack - ring social worker at 8:30 and say you need to reassess him and we are not taking him home or to the nursing home until this has been done, then we want to see written copy of the plan and discharge plan.

Ring home - advise he is unlikely to be in the home until this is resolved, but we are happy to pay to keep the place for him at the moment

Hospital are being very nice to us at the moment as we have a full complaint going through regarding the second fall whilst under 1 2 1 observations as they have already admitted liability and that's the reason he's still there.

mamadoc Tue 29-Jan-13 22:11:07

Ok so it sounds as if he does have nursing care needs: immobile, high risk of falls, incontinent, needing assistance with all tasks

You've now discovered he probably has less than the savings threshold so may be eligible to have his care funded by the local authority

BUT 1. They will want to do their own financial assessment to prove this
2. They have to apply to a funding panel to get the funding in place which takes time
3. The local authority may not fund your home of choice. They only fund a 'benchmark' rate which is less than the top places charge. You might still have to 'top up' the funding or accept another cheaper place.

It will definitely delay the discharge to get the assessments done and you may lose the place. The hospital will be very unhappy to delay the discharge for a 'non-clinical' reason.

I think that you could definitely insist that they reassess his care needs especially if not done since the second fall but if you really want that home you could go ahead with the discharge and i think you can claim money back later.
(I'm not a social worker but a hospital dr so I know the process but not all the detail)

ratbagcatbag Tue 29-Jan-13 22:12:58

Hi Iwish

His eating and drinking is better if you remind him.
The incontinence is an issue, he just suddenly decides he needs to go and then starts getting up, not remembering he can't walk and then falls over, or wets/messes himself. My MIL can't move him, she's also suffering arthritis in her wrists so changing him is difficult.
He's so scared of walking now, he's not stepped any where in a couple of months, he's either in bed, on his chair or being taken on a stand up trolley to the toilet. He can't even carry on with physio as his arm is in plaster and he needed that to use the zimmer with.

Just ARGH!!!

ratbagcatbag Tue 29-Jan-13 22:16:41

Ok so the other issue then is today my MIL put £10k in his account to take him to £27k, however I think she should remove that to take him back to his £17 which means he will get some help. Can we do that or are we going to be in trouble.

My MIL will happily pay to retain the spot at the nursing home (full fees if she has too) and pay any top up, although it's one of the cheaper ones in the area, so that shouldn't be an issue.

Mama - even if they are unhappy can they enforce the discharge?

mamadoc Tue 29-Jan-13 22:18:56

He really doesn't sound fit for just 3 calls a day as things stand if he can't transfer or weight bear but perhaps they think he could improve when his wrist heals ie still has some rehab potential. Sometimes one option is to go to a local community hospital for rehab if you have them in your area.

IwishIwasmoreorganised Tue 29-Jan-13 22:19:16

It sounds as if he still has some potential to improve - physio could be carrying on (I'm one), using different mobility aids due to his fractured wrist.

While the hospital won't be overly happy to delay a d/c for a non-clinical reason, if they had started planning for discharge in a more timely way then it wouldn't have come to this point.

Definitely speak to the SW as early tomorrow as you can and outline your concerns and ask for the financial assessment to be done ASAP.

Good luck, and let us know how you get on.

mamadoc Tue 29-Jan-13 22:22:54

Well they can't send him to a home that no-one has agreed to pay for but if you let on that you are paying for the place to be kept open they will say he should go and sort the money out after.

Definitely take the money out before the financial assessment!

ratbagcatbag Tue 29-Jan-13 22:23:33

Local community hospital refused to take him as they said room for improvement was minimal due to previous back/disc problems anyway, that combined with two new hips and they said no, even before he broke his wrist/arm.

I will let you all know how I get on, it's a good job work don't mind me dealing with stuff like this smile just need to not get so stressed now as pregnant too! My DH is good but I'm better at being assertive apparently!! Not sure that's a good thing! smile

mamadoc Tue 29-Jan-13 22:33:34

Ok so polite, calm but assertive.
Ask for a reassessment of nursing need (sounds fairly certain to me that he does have nursing needs)
Ask for financial assessment
Ask for him to be assessed for continuing care funding (unlikely but may as well try)
Don't volunteer that you are willing to pay to keep the place open unless you are happy for him to be discharged there and she can reassure you that there is a mechanism to get the money back.

fridayfreedom Tue 29-Jan-13 22:49:07

As said above his needs are beyond being cared for at home with a care package as Mil could not cope in between visits. Also sounds like his needs are nursing rather than residential. The SW should ask the ward for a nursing assessment to support this if they are going to apply for funding for his care. The SW report will have to go to panel she can not agree the funding herself.
As mentioned if nursing care is agreed then they may or may not fund the home depending on the cost, there will be a max cost they can pay. This can be topped up but not from Fil money. Ask about this now or Mil could be wasting lots of money on a place and not use it later.
Re continuing health care Fil is entitled to have the checklist done to see if he meets the criteria for a full assessment but it is very difficult to get. He would have to have very high, and I mean very high needs to get it and need very high levels of skilled nursing interventions not just carers.
They should not discharge him until a satisfactory plan is in place regardless of whether he is deemed medically fit. It has to be a safe discharge.

ratbagcatbag Tue 29-Jan-13 22:49:15

Definately polite and calm too, you get nowhere being rude and I want help and people on side smile
However not a pushover either and will not allow to discharge to occur until the points listed above are carried out. I think it helps if you go in also knowing a little but about it so you can't be fobbed off so thanks for everyone's input tonight.

ratbagcatbag Tue 29-Jan-13 22:52:09

If we get the 19k gifted to fil back then we could use that for top up of fees, is there any reason fil cannot top his own care up? Sorry I don't understand that part.

ratbagcatbag Tue 29-Jan-13 22:52:20

10 k even

fridayfreedom Tue 29-Jan-13 22:58:12

Not certain about the rules, think you need to ask the SW. If they agree to fund him he will still have to contribute from his pension and I know he will have a personal allowance for toiletries etc. sorry don't want to give the wrong info so check it out with the SW.
I would be careful about spending money and hoping to get Adult Services to refund it. They don't like this as they have not agreed to it upfront so may not be under any obligation to pay you back.

zipzap Tue 29-Jan-13 23:00:28

Also sounds like the sw was being remiss originally in not assessing him for a nursing home place, given the severity of his needs and his wife's physical limitations in being able to help look after him. She should have realised when she was doing it that it wasn't a feasible option and thus looked at the nursing home side of things too.

If the hospital complain, I'd be tempted to point out that it's hardly your fault that the team sorting out the discharge - especially the sw - didn't even do the most basic assessment for a nursing home. And that they knew the condition your MIL was in - and if they didn't then they didn't do a very good job at all on assessing your fil for going home!

fridayfreedom Tue 29-Jan-13 23:07:38

In all fairness to the SW she is reliant on what the ward staff tell her and the needs have obviously changed. Sometimes spouses also say they can cope before actually looking at the reality and knowing the level of support available at home. These situations can change by the day .
I would just calming state your case and have a list of questions re what happens next. A face to face meeting may be better if you can arrange this.

ratbagcatbag Tue 29-Jan-13 23:09:48

Will try and organise that Friday. Think it's a good plan, were not going to move him though until we get him reassessed. My mil would promise them the earth as they are medical people and much more in the know that she is. It drives us mad smile

hatgirl Wed 30-Jan-13 01:25:34

the top up has to be paid by a third party as all of your FILs income will be taken into account for his assessed charge. He will be left with approximately £20 a week 'spends' if he goes into residential or nursing care. If the care home the family wants costs more than the Local Authority are prepared to pay then the family (not the person going into care) have to provide the extra.

The social worker does not assess for nursing care - a nurse has to do this (unsurprisingly!). All people should be screened for Continuing Healthcare by the ward when they referred to social services. This doesn't always happen but is good practice.

If a person has not triggered for a full continuing healthcare assessment the social worker would not generally ask for a nursing assessment to be done if the person is returning home, as it would be a fairly pointless exercise. Once the social worker is aware that the intention is now for FIL to go into a nursing home that is when they would request/make sure that a nursing assessment is carried out. This only becomes the social workers responsibility to check because quite frankly, if health could get away with not doing it, they would!

Does your FIL have much of a role in the decision making process or is he unable to contribute much (sorry ... just realised can't go back and check everything that as been written already now i've started writing). He understands and is agreeable then it is a fairly straightforward process.

If he doesn't understand and this decision is being made for him the social worker will also have to make a 'best interests decision' to make sure that the move to that home is in his best interests and isn't going to be detrimental to him. This again may delay things slightly.

The local authority will not refund any money you pay out prior to them making a decision. It is also in the local authorities best interests to get him out of hospital as quickly as possible as if he has been decided to be medically fit for discharge then the hospital can start charging social services for him being there. This won't be the case if no one has completed a continuing health care checklist or if they are waiting for a nursing assessment, he will stay put until these are done, but there is no reason these can't be turned around in 24 hours.

ratbagcatbag Thu 31-Jan-13 17:47:23

Hi All

Thanks for all th advice, thought I'd give you an update.

On weds I rang the social worker who was releived as she was concerned we were making a mess of what we were doing and longer term we'd have an issue.
We discussed lots of stuff, but she'd stopped the discharge and wanted to meet today to do the assessments from the beginning. Initially she thought there was no medical needs and only nursing. Today when we got together she then agreed with me and said with the dementia and the risk of falls there is a medical need, she's arranging a nursing assessment as well and was explaining that although we won't get full NHS funding, we may get a level of help towards one to one. With all the details regarding MIL< she has now been completely excluded as being considered a carer, so it makes it very unlikley that FIL will be able to come home. The only issue now is whether it's a nursing home recommendation or residential home!

Everything seems to progressing well and it's definately better than where we were. The social worker is being lovely (even though we went completely round her to start with) and is being as supportive as possible.

smile

hatgirl Thu 31-Jan-13 19:15:10

social workers get used to families that are quite involved and care about their family member doing stuff like that (right reasons but wrong approach) ... don't worry you are probably by far not the worst family or the biggest problem on her caseload.

Glad you are feeling a lot happier about the situation. I hope the rest of his discharge goes smoothly.

IwishIwasmoreorganised Thu 31-Jan-13 19:39:25

That sounds really positive.

Glad you've met with the SW and feel that she's supportive.

fridayfreedom Thu 31-Jan-13 20:15:53

Sounds good. Deciding whether it is residential care or nursing will be down to the nursing assessment. It's quite straightforward in most cases, so don't worry they will sort this out.
Glad you got this sorted out, it can be a very stressy time.

ratbagcatbag Thu 31-Jan-13 20:20:13

Like I say I really appreciated all the advice, apologies my earlier post is horrendous in grammar, I'm blaming baby brain as I'm 31 weeks pregnant!!
I think compared to where we started with SW which was four visist per day to now reassessing medical need etc we are miles better off.

Only issue now is my DH and SIL need to look at actioning the lasting power of attorney for my FIL as he really isn't good and cannot make decisions etc. This was all put in place years ago, but sad that they need to do it, my MIL is also getting worse and is considering asking them to do the same for her finances too sad

hatgirl Thu 31-Jan-13 20:24:19

ratbagcatbag if at the end of al this you are still happy with the service you have received please let the social worker know even if it is just on a small level. It is such a demanding, thankless job that even the occasional off-hand positive comment from family or an individual can make a massive difference to an entire team's morale.

<completely outs self>

ratbagcatbag Thu 31-Jan-13 20:48:01

I would anyway, I am a stickler for complaining about bad services, so always counteract that by always praising good ones!

I did say today several times I was really happy how she was dealing with it, apologised that she felt she'd been left out by SIL and MIL, but they did everything with the best intentions and didn't know the process, and I appreciated that she was still prepared to help us considerably anyway, even though it must have felt like a snub, which was definately not intended.
She said it was no trouble and exactly like you said, easy to get swept up in it, she also said the ward would happily rush stuff through without her involved to free the bed up quicker smile

ratbagcatbag Thu 31-Jan-13 20:51:05

If the thread doesn't disappear into oblivion I will keep you all posted - it was such a relief to have people who knew about or were involved in the process giving advice.

They have done a Continuing care assessment twice - first was all A's on medical need, however on the recent one (16th Jan) under medical, they have moved mobility, behaviour and somehow his dementia all to B's - don't know if that will make a difference, but at least they've shifted the levels.

hatgirl Thu 31-Jan-13 21:38:12

If FIL was awarded CHC then his care would be free of charge. Make sure you are clear that they are changing the levels for the right reason.

ratbagcatbag Thu 31-Jan-13 21:42:53

From my understanding they have graded him worse now than before, so the levels changing can only help what we want longer term with regards to care.

I was told that it is very very unlikely he will get CHC however there is an element of it that would be considered for 1 2 1 care which she believes he still needs (I think she mentioned aroudn £108 per week) on top of whatever they will contribute once he drops below the threshold.

hatgirl Thu 31-Jan-13 23:58:43

yes the £108 a week will be the RNC (nursing) contribution and nothing to do with CHC. From what you have said i also think CHC is unlikely but you never know...

As are the highest score (highest needs), C is the lowest. If FIL scored A in any * (starred) domains he is instantly eligible for a full CHC assessment.

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