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If she will need help at home they can not discharge her if there is no one to help. So arrangements should be made. If she has no one then in all likelihood a stay in Assisted Living or longer term rehab if it is needed.
Rehab is by nature "short term". It's to get the patient as functional and stable as is possible; from there, plans are made for a longer term.
Talk to the social worker at the current facility about what the possibilities are--return home with help, assisted living or what.
Medicare will pay for 20 days of rehab if the therapists deem it necessary and if she's making progress. After that, there is a co-pay of about $150/ day until day 100.
Do you know if she has long term care insurance or the funds to pay for long term care? If not, will she qualify for Medicaid?
she doesn't have long term care insurance. She has a house but not the funds.
Medicare Advantages are suppose to cover A&B of Medicare with some xtra benefits you do not get with straight Medicare. You need to find out what her MA will pay. One to two weeks in Rehab is usually for those people, after a hospital stay, who need to get their strength back. Your ex has had a stroke which IMO will need more therapy than 2 weeks. She will need to continually progress. They should not release her until she has plateaued or hit the 100 days. She could be sent home with in home care and PT/OT which also is covered by Medicare. Her on going treatment should be decided by her Doctor and how much her MA will cover. That decision cannot be made until she is finished with her Rehab. Like said, she may need to go into LTC receiving more therapy there.
Strokes are tricky and depends a lot on how much damage there is and how hard the patient wants to get back to normal or almost normal.
After acute rehab (which is paid as a hospital rate) she may be able to go to subacute rehab and get further therapy.
The intensive rehab we would like is outpatient and requires 1 person stand and pivot transfer and ability to take a couple steps in walker along with 24/ 7 care.
staff thinks she could get there but...
a. Her cognition is a barrier because she is not always able to do commands
b. Her aphasia is a barrier because at this point it is hard for her to stand
They will evaluate her weekly for progress
Case manager thinks we need to be working on a plan B, adult family home or care giving at home.
Rehab up to 21 days covered by Medicare
After, she can stay in rehab up to 100 days and copay costs will be around $180 per day equivalent to the costs for private pay AL or MC. Copays should be spelled out in her contract. You can continue to ask the doctor to write for more PT.
Next comes LTC for an average of $350 per day or 130/ k per year.
Other option is take her home and provide 24/7 care yourself or hire care which will cost over 200k per year. It is paid from whatever assets she has, depending if she has any dependants like children or spouse. Before she can apply for Medicaid she has to spend down.
From there the options are in home care where someone will come in for custodial care for a few hours a week and not full time. Or she goes into a SNF.
One other consideration is who is her guardian/conservator legally. If she needs a spokesperson, you can become the person after seeing a lawyer and going to probate court for a cost of a few thousand or let the state take over. There will be pressure from the facility to pay bills that no one can access for a few months until this is resolved. Expect this to happen. Do not just take her home based on this pressure if the discharge is unsafe or home care is not put in place
How does her Medicare max out of pocket for the year and days 21-100 come into play?
She currently is only getting a half hour of therapy a day. To get more than that is not covered by Medicare?
Is it possible to retain the house and get Medicaid?
You need to ask the doctor if he feels she can ever go home to help with decisions. If her conservater sells the home, then proceeds should be kept in an account to spend down an then reapply for Medicaid again.
It is best to get her in a good facility that takes Medicaid patients early as private pay switching to Medicaid, she can stay there. Good places have wait lists for several months. If you wait till spendown, then she goes to the first available bed and it may be a crappy place. If her conservator wants to go that route, there are 100 days to sell and private pay. Even if she starts in a crappy place, once assets are at hand, applications can be made for the good ones. But it will not work that way if applying too late. The transfer would be like climbing a mountain.
You need to quickly get educated on Medicaid as payments are limited and consistent.