My mom suffered a severe TBI a year and a half ago. Everyone said she would never recover and yet we have made incredible strides and I fully believe there is a lot more healing that will continue to present itself. This has been confirmed as well by her private rehab team. My mom is currently residing in a nursing home in NYC. She is receiving top rehab - PT OT ST- and is now eating a lot and weaning off her PEG. She is in a wheelchair but can move her body. She is now able to move her entire body despite her left side being dormant for sometime and every doctor saying she would never move or walk again. She went from not speaking at all to being "fully back" and being able to communicate clearly. She wants to go home. Currently we do not have a home to take her home to but we may in a year's time be able to get her home to my sister in Long Island. She has Medicaid and Medicare. I have tried repeatedly for over a year to get great clarity and information on where I go to figure out if bringing Mom home at some point is a real possibility in terms of the care she would receive or not. I've called Medicaid, the nursing home social worker, the program Open Doors, the # for the Medicaid TBI voucher program... NO ONE can answer my questions and all are wildly uneducated. Where do I go to get such info?
So, I believe the county case worker should be able to give you the most guidance. Just get mom set up to move first because they can't answer for possible scenarios in the future.
I would advise you and your sister to carefully consider whether moving mom to her home in Long Island will be the right choice. I'm glad your mom has progressed so nicely and wants to go home now, but she doesn't have a home to go to, and she realistically can not live on her own independently.
If her Medicare/Medicaid will cover it, look into Assisted Living for your mom. She would have her own apartment, with housekeeping and meals provided and nursing assistants to help her with ADL's.
Moving her in with family may work just fine - for a while. But, she will in time need more and more help with personal cares. Is she currently able to go to the bathroom on her own, or is she incontinent? If the PEG tube is removed, is she able to chew and swallow safely? Have a Speech Therapist evaluate her swallowing. Managing incontinence, feeding and medications are the most laborious tasks, along with mobility, if she can not get around entirely on her own. And, of course, there's always an adjustment when adding another person to your home. Are their personalities going to clash? Are their lifestyle preferences compatible?
If you and your mom and your sister are all agreeable to the living arrangement, go ahead and get her moved first, then call the Medicaid Social Worker and ask how to get in-home care paid for on the TBI voucher. (Here's the thing; if your mom has made so much progress that she doesn't need much help with her ADL's, then Medicaid will not see that home care is needed for her.) They don't just "pay" a family member to take her in. Does that make sense?
And, if you're asking what the program could help with in a year from now, no one can answer that, as there are so many variables that could change by then.
One upside to a good facility is the social aspect. If a senior becomes housebound, especially due to incontinence or high fall risk, they can quickly become isolated, even with one or two family members or caregivers in the home. A good senior facility will allow them to participate in activities. My mom is one of the highest functioning people in her MC, but it has been good for her socially. She attends concerts, goes on field trips, plays Bingo and gets her hair and nails done. This month so far they have had a fireworks show, 4th of July crafts, concert/picnic with homemade ice cream, cookie decorating, nails done, games, and a candy tasting. Mom is incontinent, a fall risk and wheelchair bound. There is no way I would be able to safely match the social aspects of a good facility like that. Just something to think about longterm.
Her mom wants to "go home", and an assisted living or Memory care apartment can be her new "home".
Your mother needs 24/7 care otherwise she would not have been admitted to a NH full time. They don't keep people there if they do not need to be there.
If you do persist with this, just know you are not going to get enough caregiving hours from in home Medicaid. You also will not get reliable care from a Medicaid agency. Caraegivers are underpaid and they oftentimes don't show up. If you insist on doing this, you would have better luck putting a team together of caregivers that you hire. That requires a lot of money. If your mother is on Medicaid she doesn't have the money, but maybe you and your sister do.
So if your mother is on Medicaid in a nursing home I would not bring her home. She will get better care being there. She recovered her speech and some movement so obviously she is doing well in the facility where she is.
I know that sounds harsh but it is the sad reality.
https://www.agingcare.com/questions/deciding-between-long-term-care-or-bringing-mom-home-493461.htm
You do not mention your Moms age. Of course she is improving because she is getting 24/7 care. The facility can evaluate her to see if she can go home but you have to be able to guarentee that she will get the care she needs to continue to improve. That everything is set up to be able to do the care. If you are going to need Medicaid in home care, Mom has to fit the criteria financially. They don't give 24/7 care in a home setting. You will be lucky to get 8 hrs. There is in home PT that medicare may provide but the care is intermittent. Meaning only so many days during a period. Then you need to wait maybe 60 days to qualify again. In that time Mom could go downhill.
To care for someone at home is not easy. No one should give up jobs to do it. Or abandon their families. If your sister has retired, caring for someone can be exhausting and the older you are, more so. And, will there be a village to help her?
Of course Mom wants to come home but its not all about Mom. There are other people involved with their own lives. Its not what Mom wants but what she needs.
Call your Social Services Dept and ask if you can set up an appt to speak with a caseworker concerning In Home help for Mom. You could also consult with an Elder Lawyer.