When I was the Director of Social Services at a long-term care facility, I saw the same situation time and again. The family members of patients being discharged would come to me overwhelmed and uncertain they could meet the newfound needs of their senior loved ones. They’d ask me what to do, and I would reply: “Have you considered home care management?” Then they would look at me, baffled. Many of them had never even heard of such a thing!
My role in planning for discharge services was very similar to what a care coordinator does in the community. To gain a little more insight into the role, let me take you through a fictionalized version of a day in the life of these geriatric professionals.
How a care coordinator’s day unfolds
Let’s follow around a care coordinator I’ll call “Ms. Perkins.” Ms. Perkins received a call yesterday with a new referral from the geriatric care organization for which she works. The name of the person requesting the referral is Mr. Bell. Mr. Bell’s elderly, widowed mother has just returned home from a sub-acute rehabilitation center (SAR) after being hospitalized for a stroke. Mr. Bell is concerned his mother will no longer be able to care for herself now that the stroke has left her with limited physical capabilities.
Ms. Perkins drives to Mrs. Bell’s home and meets with her and her son. She reviews Mrs. Bell’s medical records and completes a comprehensive assessment and individualized plan of care for her new client. She makes several recommendations for Mrs. Bell’s new status, including a home health aide a few days a week and a stroke-recovery center for ongoing support.
Ms. Perkins drives to her next appointment with an ongoing client – Mr. Deer – who needs medical care coordination. She accompanies him to a medical appointment, asking questions and taking notes from the doctor. After the appointment, she calls Mr. Deer’s daughter to keep her informed on his progress.
Next, Ms. Perkins conducts a home safety evaluation for another new client, Mrs. Tea. She notes that Mrs. Tea’s eyesight and balance have declined recently, and items in the home, like frayed rugs, low tables, and dim lighting, now present a fall risk. She makes a recommendation for several improvements to Mrs. Tea’s nephew and faxes them to him.
On her fourth appointment, Ms. Perkins visits a recent widower and assesses him for depression. In addition to a mental health referral, she offers to coordinate additional services for him, such as housekeeping, transportation, and meals. These are functions formerly handled by his wife, and without her, he is having trouble keeping up with them. He agrees to consider the services.
The rest of the day is dedicated to family consultation, education, referral, and support for the victim of a heart attack, assistance with long-term care planning for an ailing client, and a recommendation for medication management by a licensed nurse for a client having trouble keeping track of his prescriptions.
A day in the life Ms. Perkins may involve many additional activities that are not listed here. And seeing a care coordinator in action may lead you to believe that these are just friendly and concerned individuals. But those who specialize in home care management are so much more. They are often licensed healthcare professionals; many are members of organizations such as the National Association of Professional Geriatric Care Managers (NAPGCM) and the National Association of Social Workers (NASW).
Home care management is a vital service for seniors
As you can see, home care management is often vital for seniors, and care coordinators play an essential role in the spectrum of services. Often, the coordinators are able to pinpoint challenges seniors face before they become major issues. This helps protect your loved one’s health and well-being, and may even save their lives. The role of the care coordinator is always busy and ever-changing – there’s never a dull moment in the lives of these caring professionals!
If you are unsure of how to best help an aging loved one, the trained and compassionate staff at the Institute on Aging is here to help you make that decision and gain the best in at-home senior care. Contact us to find out more.
