Handhold or advice please

[DorsetCamping]

Would very much appreciate support or advice on making short term steps with my DM.
I have posted before about her declining health and care but things have pretty much reached a crisis point now.

To cut a long story short she is currently in hospital for the 3rd time in a month, with the current admission now on day 10. She has a myriad of conditions, none of which has been managed properly within the community (especially since lockdown) and this latest emergency almost caused her to die over the weekend.

Amazingly she has recovered and the doctors have deemed her medically fit for discharge. All well and good but I firmly believe she is not safe to go home and am petrified that as soon as she returns she will fail very quickly and just end up ping ponging again. She is extremely weak, confused and can do very little for herself - my hope is that she will improve somewhat but believe she is on overall decline.

When she was discharged last time a short term care' package was put in place, with visits 3 x per day. However the reality was they would literally make a cup of tea, ask if she was ok and leave. I am not moaning about them but that package is far from what DM really needs and meant that everything actually fell to me.

So here we are now, and I'm waiting for a call to discuss the discharge plan. I feel utterly sick that they will just send her home again (she lives alone) re-start the basic care and leave me to do the rest. I myself am a key worker, with children at home and have spent the last 8 weeks flying between DM, her GP and the hospital, when each crisis arises. I am exhausted and not sure I have the mental strength to deal with yet another emergency - which I can guarantee will happen if this isn't managed properly.

So after relentless reading up and trying to research what is on offer in our area I 'believe' In in the very short term I have 2 options, however when I have put these forward all I hear is 'budgets, demand, qualification, lack of resources' To my mind what more does someone who can't dress/wash/cook/manage medications or their multiple health conditions/on their 3rd hospital admission, need to do to qualify??

So the 2 options are:

-Short term respite at our local community hospital so she can recover and be properly supervised. All the necessary services can be engaged to provide a joined up care plan to help her and hopefully prevent another hospital admission.

• demand that if she goes home a more adequate level of care is put in place I.e. she is medically supervised and thorough checks are carried out to ensure she is managing her conditions

Someone has also advised that a 'case manager' is put in place so a proper joined up approach can be taken. The lack of care throughout lockdown shown by both her GP and the Community service has astounded me and is a big part of the reason she keeps ending up back in hospital. I am aware that the area we live in is extremely under resources for District Nursing etc but it seems so short-sighted.

So sorry for the incoherent rant, I feel like I'm wading in treacle with this but am desperate to get a handle on this before the imminent discharge.

If there are any options I haven't thought or any experiences I would be most grateful .

Hi, I'm no expert so all of this is just my opinion/experience, but am certainly happy to handhold, it sounds extremely difficult and stressful - who is the call you are waiting for from - social services or the hospital? The difficulty I always find with my mum who has multiple health problems is that hospital are mainly just keen to discharge and get her 'off their books' asap and rely on family heavily to plug any gaps, but social services often won't engage properly while someone is still in hospital or under NHS care as 'not their problem'.

If I was you I would try and be very firm that you cannot provide the level of care you previously did and reiterate over and over that you do not feel she is safe in the community and you are not prepared to do more than social care such as shopping (even if in an emergency of course you would help, as soon as you admit this it gets written down as 'daughter will provide care').

It may vary by area but in our area the absolute maximum 'social care' someone will get in the community through social services is about 3-4 hours of care per day over 4 visits, unless the person funds more themselves, because social care is not meant to cover medical needs, just things like feeding, dressing, washing etc. They will remind/check medication has been taken and call an ambulance in an emergency, but the carers will not be medically qualified so can't do much more than that. District nurses are also not meant to provide constant care/clinical supervision, their model is more to visit to provide specific things like changing dressings, providing medication etc. so I wouldn't necessarily focus on them either. It is possible to get a more comprehensive care package provided at home but this is usually only where someone is assessed as eligible for 'Continuing Healthcare' i.e. they have serious multiple medical needs- has your Mum had this assessment recently? - if not I'd ask for one asap. To be honest where an elderly person needs 24/7 care you are probably looking at a care home unless you are prepared to fund/employ/supervise your own carers and/or do a lot yourself, it is just too resource intensive to be funded in the community for most people, I know this is probably really difficult for you, but have you thought about whether the time is approaching to look at residential care - if so it would be better to try and do this in a planned manner and take some time to look around at the best possible option, rather than letting it get (back) to crisis point and having to do everything as an emergency?

In the meantime I think the rehab option sounds like the best thing for her - I'd push for that as gives you a bit of breathing space and a good rehab/community hospital will be well placed and have the time/space to make sure all the relevant assessments are done and proper advice/MDT input given to form the best ongoing care plan for her (as opposed to an acute medical ward who will just want the bed back asap)?

Sounds like my father a year ago. He is now in a nursing home and physically is in much better condition. We did it via an emergency admission, which is not the best way to go about it, although we were very lucky in where he ended up.

Thank you for your replies, I have an update...
After what seems like an interminable amount of phone calls, chasing and arguing with both the hospital and DM, fingers crossed she is being moved to a rehab unit today!

Everything has been a huge battle from every angle but relieved that she is at least not been sent straight home. The place she is going to is a local care home with a rehab unit which has nursing staff, OTs and PTs. It sounds exactly what she needs to recover from her ordeal and give us time to ensure a comprehensive plan is out in place moving forward.

Sadly DM seems to have reverted back to toddler behaviour, sees no positivity in going to rehab and is being very truculent. Not a word of thanks for anything that is being done to try and help her or keep her safe. I am clinging to the fact this behaviour is because she is really scared and exhausted from being in hospital for nearly 2 weeks, but actually proves that she really does need to be in a 'halfway house'.

In response to my request for a Continuing Healthcare Plan assessment I've been told there is next to no funding and anyway all assessments are on hold during COVID crisis

One resource that someone suggested is a Community Matron who takes a holistic view with management of DM's conditions and monitors engagement of the various agencies. Ideal on paper but obviously there are waiting lists and no good when DM needs the service now.