I was pretty naïve Palm Sunday when I called the nurses’ station at a skilled nursing/rehab center where my 91-year-old mom is currently staying and asked them to do me a favor.

“Hi, my name is Melanie and I’m Ginny’s younger daughter” I began. “When you have a moment, can you go to her room and turn on the television and put it on CBS? Tiger Woods has returned to play in the Master’s Tournament and I think she might benefit from watching something she loves.”

“Yes, I’m actually her nurse and I can do that.”

Many readers of the blog may remember that I have previously written about mom’s devotion to Tiger. In addition to watching every tournament he’s played in, she actually created a newspaper collage in 2019 after Tiger won his 5^th Masters Tournament, taping it to a side mirror on a wall.

“What do you think?” she had asked, grinning when I turned the corner of the room and first saw it.

“I’m blown away” was my truly honest reply. I had never seen her do anything like that in my life.  Somewhere, somehow, she connected to Tiger. In fact, even when she was placed in her first Memory Care unit, she was telling ME about Tiger’s near-fatal car accident; there was a television in the common area.

With my call, I had hoped that watching him, even for a while, might bring some joy…and focus. Honestly, it is a miracle he is playing golf again at all.

I visited Ginny just a few days later. After a hospital stay in late March, she had been transferred to a medical facility for rehabilitation. The second floor has 60 rehab patients and the first floor holds 60 residents in long-term nursing care. Given her previous assessment (click here), I was more interested in placing her in advanced nursing care.

But in the medical maze of Medicare, she could receive advanced skilled nursing on a temporary basis only if she entered “rehab” directly from the hospital.  And having her in “rehab” would provide time to consider Ginny’s next step. We already knew that she would not be returning to her room at her Memory Care facility as it was clear her needs are advanced now, not to mention that the chronic staffing shortages (which have literally crushed the entire healthcare industry over the last two years) were affecting her well-being there.

So, my husband and I joined my sister and her husband in a “family care planning” meeting to discuss options. This is a standard meeting scheduled by the rehabilitation center for all patients.  The term “rehabilitation” does feel at odds with the reality as her doctor had referenced hospice only three weeks prior. But with new medication to calm her dementia and erratic behavior, and a small amount of physical therapy to keep her moving (she is in a wheelchair now), hospice was not part of the conversation.

 We focused instead on our wish to place her in a long-term nursing care home once she is discharged. There was a brief mention by the director of Nursing about alternate Memory Care options and “activities” for mom, which was slightly alarming as she didn’t initially seem aware of mom’s condition. We explained that there would be no more Memory Care. In hindsight, I wonder if they thought she was “exit-seeking” which does require a specially designed space with safety measures to keep them from wandering. I can only say that there isn’t the slightest chance that she would travel from the second floor to the first and then find her way out of the front door. She is barely mobile.

Choosing a long-term nursing home, however, does squeeze us into a corner because Medicare will only be paying for “rehab” for so long, and finding a new “bed” is easier said than done. The place she is currently staying in has a wait list for their long-term care housing floor and they are not alone. Many of the better nursing homes have wait lists. To clarify, an example of “better” includes plenty of qualified staff, an M.D. and/or Nurse Practitioner on site, respectful interactions with the patient, a clean environment and extras such as a beauty parlor and enrichment activities. Realizing that every adult child naturally wants this for their aging parent, only raised our stress level astronomically for finding something before she was discharged.

Unfortunately, the social worker, an employee of the Center and the person who works in conjunction with Medicare and Medicaid to find a “bed” was not present at the meeting, so we left with no compelling answers other than she was not on the schedule “yet” for discharge.  We were assured that they wouldn’t release her until there was a solution, but finding that felt like a Sisyphus task; and would it be the right solution for her?

Then, a new day dawned. We returned to the facility with the single focus of seeing mom once more before we started our long drive home.  While there, my sister suggested that we look for the social worker in her office and have an impromptu conversation.

It worked. She happened to be in her office and she had received notes from the Director of Nursing regarding our discussion the previous day. And without hesitation, she said something that the four of us will remember forever.

“We’ll just keep her here” she announced. “She is scheduled for discharge from rehab in 8 days, but we will just keep her on that floor until there is an opening on the first floor.”

I heard my husband ask “is this a dream?” It was absolutely surreal. If we hadn’t popped in, we’d be driving home still stuck in the maze; digging for ideas and new alternative places to call. Surprise, relief and gratitude washed over us as we all four stood awkwardly in her small office.

It had been only 20 hours ago that mom was theoretically at the end of every wait list for every facility.  We had also been given no encouragement for placement right there. What had changed? What paperwork and checklists and patient reevaluations for Medicare and Medicaid were completed which allowed them to be willing to suddenly “hold” her indefinitely upstairs? The senior healthcare industry is so layered and intertwined with the government and rules, it is overwhelming to try and follow their complicated alchemy.

I found a quote in a senior care blog from The Stanford Center for Longevity where the author states “Although I earned a doctorate in public health. I could not navigate the health care and elder care system successfully for my mother. She was hospitalized five times in the last year of her life; three times in the last two months of her life.”

If he couldn’t, the general public doesn’t have a chance in the maze. We will probably never know what changed for Ginny.

On that first day, I had gone up to the second floor to spend time with her. She had been to lunch and was now in the hallway in her wheelchair. Her head was down, but when I said “I think that’s mom right there” to the nurse accompanying us, her head moved up and she looked straight at me. She knew my voice. We wheeled her into a vacant “Activities” room.

It was then that I realized that she would not have been able to either watch or understand about Tiger Woods. She was less verbal than my last visit. BUT more than once, she looked directly at me with an extended intensity, staring at me like she was willing me to understand something in her mind. I strongly felt the connection she was creating, but was unable to decipher her silent message.

And her connection with Tiger provided yet another new parallel. In the same week, they both experienced their own versions of a miracle.