Geriatric ward say one thing, occupational therapist over-riding - anyone had experience of this?

[Gazelda]

MIL (84) had an op a few month ago and has been bed-ridden ever since. After about 2 months in hospital, she was discharged on 5 Oct home to her flat with 2 carers 4 times per day. This inadequate level of care led to numerous falls out of bed, infections, ambulance calls, hospital stays etc. She's been in frailty ward and geriatric ward since Saturday.

DH spoke to frailty nurse and Doc on tues who said that they and the ward's Consultant believed that MIL requires 24hr care. DH asked whether this meant rehabilitation/respite and he was told that yes, this is what they recommend.

We've been waiting since then for a placement to be found.

This evening, DH took a call from occupational therapist who said that whoever DH spoke with on Tuesday did not have the authority to say what they said. A meeting is to take place tomorrow to discuss long term care for MIL. DH was asked if he wanted social services to find somewhere for her or whether the family will make private arrangements. DH was blindsided by this call, which contradicted his understanding following the conversation with the doctor on Tuesday.

Does anyone have experience of two contradictory conversations? And how does DH regain some input, voice and control in this, on behalf of his mum?

I’m confused sorry.
You were told that mil needs 24 hour care by 3 experts and the OT said that they did not have the authority to pass on this (fairly obvious) information from your description?

Surely you will just go to the MDT meeting tomorrow to gather the information and make decisions then?
Your DH and his mother will be included in this meeting I presume?
Very sad situation for you all, I’m sorry that you are experiencing this.

In my experience (nurse working in frailty service in the community) the OTs and physios are usually very good at determining what they often call someone's "rehab potential" I.e. whether they will benefit from rehab or whether from a function point of view how they are now is as good they are going to get. It sounds everybody agrees that MIL needs a residential setting but there is confusion over whether this would be temporary (rehab or respite) or permanent (residential or nursing home placement).
Can you/DH attend the care planning meeting? That should be attended by different members of the team and usually would have therapy input, I'd ask them how/whether her rehab/potential has been determined.
It might be as simple as the medical team saying "yes" to your DHs respite question when really they more accurately meant permanent residential care.

In terms of your husband's input into planning her care, does MIL have the ability to express her wishes? And does she have mental capacity to make decisions around her discharge arrangements? Does DH hold a power of attorney for health & welfare?

Good luck

What does your dm want? Surely if she wants to move to 24 hr care then they cannot stop it? Does she have capacity?

It sounds to me like your DH might have misunderstood what was meant by 24hr care? It's not respite or rehabilitation, it's moving into a nursing home. Rehabilitation or respite would mean a return to her own home at some point and the patient would have to have the "rehab potential" for this to happen. It sounds like the wars team are saying she needs permanent care, not short term.

Thank you all.

We're pretty confused, to be honest.

She was originally discharged on 5 Oct on a 4 week re-ablement package, which we're 2 weeks into. Every time we expressed to her social worker that, in our opinion, 24 hr care was needed, we were rebuffed. To be fair, MIL was also saying that she didn't want to go into full time care, she was determined to stay at home. She has been assessed as having full mental capacity.

So it came as a relief when 24 hour respite was suggested on Tuesday (as far as we understood). And it's come as a bolt out of the blue this evening to be told that it will be a permanent arrangement.

What's changed since she was assessed to be suitable for re-ablement on 5 Oct? She was further discharged from hospital a week ago (after 3 night stay) because the social worker deemed her fit to return home under the same care arrangements and our protests because the social worker assessed her as having mental capacity and MIL was adamant she wanted to be at home.

DH felt bamboozled by the occupational therapist tonight, and feels as though any last shred of control he might have over the situation has been removed, as has any opinion his DM might express.

Was she discharged a week ago and then re-admitted again after a fall etc? If so, that's possibly what's caused the change in tack - reablement isn't working. It's also a form of assessment and it might be obvious that it's just not working, regardless of what mil thinks. Of course if she has capacity she can't be forced into a nursing home, but if she goes home again you might just be back into the in-and-out of hospital situation. It's really hard! I think elderly people's functional ability can go downhill very fast sometimes, especially if she's been in hospital for protracted periods. It also sounds like your dh and his mum have different opinions from what you've described- he/you think permanent 24 care would be best, she wants to go home? I agree that you should try and go to the care planning meeting and get a better idea overall of what further assessments etc they might have done while she's been in hospital for then to reach the 24 hr residential care recommendation.

DH felt bamboozled by the occupational therapist tonight, and feels as though any last shred of control he might have over the situation has been removed, as has any opinion his DM might express.

Unless your dh has legal powers he doesn't have any control over the situation, and even less so should she have capacity.
If she's adamant she wants to go home and has capacity, no-one can atop her. Did you post about this recently as there's a similar thread very irate about how hospital staff won't agree with family about what to re discharge planning when it's against a DM who has capacity wishes.

Atop should be stop

Was this definitely something the frailty nurse suggested or was this something your DH suggested and they have agreed this might be necessary and he has run with jt, hearing what he wants to hear.

If your MIL wants 24hr care there's nothing stopping her. She has full capacity. But she may have to pay for this privately if the medical professionals don't deem in necessary

Can you just clarify exactly what it is you’re not happy about? Is it that you don’t want MIL to be seen at this stage as going into permanent residential care, but think rehab should be tried before that decision is made?

Your dh & mil seems to be strongly focused on her mental capabilities all the while ignoring her physical incapabilities.

She may have capacity and be adamant about her ongoing care but she needs 24 hour care because she is bed bound and unable to physically do anything for herself.

Unless she can afford 24 hour care at home, plus the equipment needed ie hoists/wheelchairs, raised chair, table to fit across the chair and hospital bed, incontinence products/clinical waste facilities, ppe for staff, then a nursing home is the only other option.

So this is not a short spell in a nursing home until she is on her feet…is that a possibility? Do the OT staff feel that this is a strong possibility?
It sounds very much like she will need residential care for the rest of her life now.

@Purplewithred

Can you just clarify exactly what it is you’re not happy about? Is it that you don’t want MIL to be seen at this stage as going into permanent residential care, but think rehab should be tried before that decision is made?

Yes, this is exactly the situation. We've been led down the re-ablement path for so long. MIL has been given hope that she can remain in her flat.

The reality is that we (DH and I) accept she needs 24 hour care and that a care home is likely to be the best place for this. But ever since her original discharge from hospital, we've felt un-listened to. Almost bullied into accepting the reablement package as if there were hope in physical improvement. And MIL has clearly said that this is what she wants.

Then the call on Tuesday felt like at last someone was listening to us. Had mum's best interest at heart rather than £/'the system'. Allowed for MIL to go into a home temporarily while she gets stronger and then a review could be taken about the long term future.

The call last night took away all hope of our voice being heard. And, in fact, of MIL's voice being heard. And, it seems, the doctors' voices and the frailty nurse's. All hope of physical improvement seems to have been removed, despite my DH very clearly asking for clarification from the doc on Tuesday that he was suggesting temporary placement rather than permanent at this stage.

Ultimately, MIL knows that we feel a care home is for her best. But we wanted it to happen a bit less brutally than this feels.

If you/MIL want to try a private respite/rehab admission then no one can stop this, but it would need to be privately funded. Is this what you mean?
I'm still a bit confused as to what your MIL wants.
I know it feels and comes across as brutal to you, but the nhs when it comes to hospital beds doesn't have the luxury of funding/providing beds to people who no longer have an acute medical need. Are they saying she is medically fit and is at her baseline for rehab?

Your husband needs to speak with the hospital social work team. The ward should have already informed this team of MIL’s admission. Your MIL will be assessed, both in terms of her capacity regarding her discharge and also her care and support needs at this time. This assessment is called Discharge to Assess.

The plan following discharges of this nature are usually broken into small steps, so if the therapy staff are saying there is some rehab potential, then your MIL should have the opportunity for rehab, whatever the long term plan for her may be. She had the right to be able to mobilise and complete daily
living tasks at her optimum, wherever she is living.

If she is deemed to lack capacity regarding discharge, her wishes will still be taken into account. Just because she lacks capacity does not mean that social care/health/family can actively go against her wishes.

Remember, the aim is to

1. Enable her to achieve optimum level of independence, whatever that may look like.

1. Ensure her well-being. Whilst the safest option for her may to be in a residential setting, this may be detrimental to her mental well-being. Remember, people still fall in residential settings.

If a return home is to be considered following a period of rehab, ensure that the support will be enough, she may need some through the night calls to support her with accessing the bathroom.
Also, have a look at telecare equipment, falls bracelet, sensor mats, lamps that turn on as the person gets up from bed. These all make a huge difference to a persons safety and response time should they fall.

The hospital social worker needs to be at the MDT, as, dependant on the outcome and your MIL’s finances, the local authority may fund the placement if it doesn’t end up being rehab.
Also, it’s better that she is known to adult social care for the step following discharge.

So
The OT is right. It's not for the ward doctors and nurses to determine her social care needs or discharge destination unless it's to another hospital. It's not uncommon for medical staff, who are good at their field to "prescribe" care home for nearly everyone! We'd having barely anyone living at home if we let ward nurses and doctors dictate as they not understand legislation nor responsibilities in that area, they are experts in their own field not others . Same as social workers would definitely fill up wards with people urgent for hip replacements if we were allowed to overstep our area of expertise!

First question, does Mother have capacity to decide on where she wants to go to after discharge?

If yes, what you think is useful to know but doesn't lawfully override her rights to decide between options offered snd even to make an unwise decision.

It sounds like OT is part of MDT discharge assessment team. She / he or a hospital social worker will be assessing mums needs and looking at options offered and what was causing all the difficulties in between 4x daily care calls at home before (was she also acutely ill or had infection and that is resolved now for eg?)

If Mum lacks capacity following a capacity assessment - there will be a best interests consultation and if needs to be least restrictive option that best meets her needs. Do any of you have LPA health and welfare?

It sounds like you need to engage with current assessment process, so that they hear your information about life at home and your worries, as part of that assessment and ask to be involved in (virtual) discharge planning meetings if being held for her and to be kept updated

Ah, I see. Having read it again, you feel re ablement stay at a discharge to assess placement is the right way to go. But mum has stayed in hospital for 2 months waiting for one , so that 6 week period has occurred in hospital anyway , and often it's the OTs that lead that rehab potential assessment. If they assess her as being at optimum and unlikely to benefit or change significantly from further rehab , then D2A bed may no longer be an option. So therefore they'll be planning for ongoing long term needs

Attend the meeting (usually it's a virtual one currently) - I'm sure they'll explain it all and explain the options and what your Mum says she wants between the available options

During the last year or so there have been new'pathways' out of hospital being developed to try and prevent patients during in hospital beds whilst people argue over next steps. These new rules have inevitably been interpreted differently by different councils and trusts. I work in a hospital that treats patients from 3 Counties. In one of the counties we no longer have social workers based in the hospital. If a patient needs a long term' placement' in a care home, they are discharged to a 'Discharge to Assess' or sometimes ' reablement' bed in a care home and then a social worker will get involved and advise re long term plan. For some patients this is a good plan but if you're mother had had 3 months immobile and had unsuccessfully trialled being at home with 4 times a day double up, (which for most councils is the maximum they will find, ) it would be much more appropriate to discharge her to a long term care home bed.
What I am saying is that might not be possible to do under whatever contract your Council Social work team are commissioned. If your MIL had resources to find her own care, and you are able to find somewhere, you can just tell the ward that that is your plan. However, unless a bed is available immediately, they may still move her our into a community need to free up the acute hospital bed.

All the time your MIL had been in hospital she will have had regular input from OT and physio. They have to decide if she has rehab potential. If she made no progress in 3 months she is extremely unlikely to now. I think ironically the OT has been listening to the fact that family have been saying for a long time that she is not safe at home alone between calls. So I am a bit confused as to why you are upset with the OT?
What you are actually saying it's that you would prefer that t the team pretended she had the possibility to get home and sent her to a rehab bed ( preventing someone else who needs rehab to go to that bed ) just to give her longer to get used to idea she cannot go home.
It is devastating for some elderly people to not return home from hospital but it sounds like you're MIL had had 3 months to consider the likelihood of that followed by a trial period of following her wishes which was unsuccessful so she had already been through that process.
If they have offered a discharge planning meeting, just accept and attend and say your but and listen and hopefully everyone will be in agreement with what is needed.

I can't thank you all on this thread enough.

Although I may have come across as confused and contrary, you've all helped clarify our minds and give us focus on what we/mum wants going forward.

She's today been referred for 4 weeks nursing care in a home. With review after that point.

She's now told the hospital team that she thinks it best if she moves to a nursing home after that, but I think wants to keep her options open for as long as she can.

Again, thanks for talking us through this. It's honestly helped enormously.

Does she have insight into her physical capabilities? For example - Is she doing exercises in the chair by herself or is she just snoozing. Is she trying to help getting dressed and attempting do her hair or just waiting for the staff to do it all