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I feel bad that the Case Manager/Social Worker didn't take care of that for you before discharge.
There are Home Health Agencies that will conduct an interview and see what services may be covered. But, for Home Heath there has to be a Doctor's referral and the patient must have had a recent face-to-face office visit as part of required criteria.
Honestly the Discharge Planner at the hospital probably should have had a discussion with him.
In Rehab they should have had a discussion and a Plan of Care before he was discharged.
Now at this point you search for services that will help him. Some are going to be dependent on his age.
If he is a Senior his local Senior Service Center may have information that will direct him to services he may qualify for.
If he was in the Service the VA may have programs that will help him. Contact (have him contact) the local Veterans Assistance Commission or the VA and ask for a Patient Advocate or a Social Worker.
How much help does he need? you mention a "sitter" does someone need to be with him 24/7? If so maybe Assisted Living facility is what he should be looking for.
https://www.nahac.com/find-an-advocate#!directory/map
https://www.aginglifecare.org//
Your county office of aging or regional senior center are also good source for advocacy.
I am a board certified patient advocate since 2019. I work with clients in New York State, and especially in my own county because I have so many contacts in long term care here.
Best wishes to you and the care recipient in healing and in building the support system you want.
To find a patient advocate you can try the following approaches:
1. Ask your healthcare provider. Doctors, nurses and hospital staff often have recommendations for patient advocates.
2. Hospital or Clinic Resources: Many hospitals and clinics have patient advocacy departments or staff.
3. Insurance Company. Some insurance companies offer patient advocacy services as part of their benefits.
4. Professional Organizations: Organizations like the National Association of Healthcare Advocacy (NAHAC) or the Alliance of Professional Health Advocates ( APHA) can provide directories of certified patient advocates.
5. Online Search: Searching online for patient advocates in your area can yield results, especially from directories and professional websites.
6. Word of Mouth: Asking friends, family or support groups can lead to personal recommendations for patient advocates.
Best of luck in finding the right support and take care.
The primary care doctor can write orders for home services. Please Note: There are Social Workers in the hospital and upon rehab discharge there should be follow up with whatever specialist and/or primary care doc is overseeing everything. I'm surprised this wasn't ironed out beforehand. You are going to have to be proactive and ask a lot of questions and be willing to make that 5th phone call to get what you need.
You need a home assessment. I would contact the Nurse Case Manager "before" the person is sent home from the primary care doctor's office. They seem to know more about services than the doctors.
My motto has always been especially if one lives alone or there is the "solo" caregiver, "bring on the troops". By that I mean, physical therapist, occupational therapist, home blood draw. Really study your loved one's health insurance plan. There are a lot of services provided that will get you through. A nurse will do a home visit to assess everything. Don't be shy and do this alone.
Also, I am a firm believer in home visitation by the local Church. Even if they are not formally registered to a particular Parish, find one, call up and register and asked that a home visitation be provided weekly or whenever volunteers make their rounds.
A call button necklace with a GPS tracker. Good durable walking shoes. Get rid of throw rugs. An Up Walker Lite not the aluminum gray walker that are passed out upon discharge and everyone walks all hunched over once the person is, if possible, able to gain their strength and get around. The gray one's are ok in a home in small quarters.
You can request a female CNA if it is a women to shower. Make sure they have enough water to prevent dehydration and UTI's. Everything today is a website, a voice mail and (3) departments later you finally have a live person pick up.
Check their toe nails if they need clipping and also their ears for wax removal so it won't read as Dementia. Hearing aid batteries need changing, etc.
It's a full-time job. You don't want them discharged and (3) hours later they fall and are taken out in an ambulance and wait 10 hours in the ER.
I have been in the trenches for some time now and I hope I was of some help. A landline with large numbers comes in handy too. Make sure the person's grooming is attended to.
- Caseworker from social services for your county (call them for an in-home needs assessment) they can provide light housekeeping, food prep, hygiene assistance
- MPoA assigned by the patient (as a manager/advocate)
If this person has a church they regularly attend, request help but if these volunteers aren't looped into what other aid and services are in place, it can be counterproductive and disorganized. Best to have them fill unfilled care needs, but keep in mind this is a temporary help.
I am not saying that it’s not worth visiting them, as they MAY have valuable resources or advice. In my experience, they just hand out scribbled notes with websites they’ve Googled, as anyone can do.
Most states have an Ombudsman who can help you get these messes. Search state Ombudsman for health care