Care Coordination Roadmap

 

Family Consultation

Care Coordination RoadmapOur Geriatric Care Manager or resource specialist conducts a consultation with the elder and/or the family before creating a care planning and coordination program. This consultation is done in person, depending on the needs of all involved. During the conversation, the Geriatric Care Manager or resource specialist will:

  • Learn about the family situation
  • Explain the care management process
  • Determine if care management is an appropriate alternative
  • Provide referrals to other agencies if necessary
  • Provide referrals to other professionals if appropriate
  • Discuss our fee structure and program options

Assessment

Our Geriatric Care Manager conducts a detailed bio-psycho-social assessment of the client(s). The investigation is specific to the situation of the elder, their current condition, and the types of services being considered. During the assessment your Geriatric Care Manager will:

  • Assess activities of daily living, intellectual functioning, decision making capacity, and emotional status
  • Evaluate social interactions, isolation, recent changes and conflicts which affect quality of life
  • Investigate mental and emotional health, current outlook, and effects on physical health
  • Check legal documents are consistent with current situation, identify conflicts, and check for appropriateness
  • Inspect the home environment for safety, security and consistency with elder’s current and future needs
  • Evaluate medical condition and health care needs including in-home and in-patient care

Elder Care Plan

After the assessment is complete, your Geriatric Care Manager creates the care plan, a roadmap that spells out how every aspect of care will be handled and what roles the elder, family and care manager will play. The goal of the plan is to maximize quality of life, and keep or return the elder to the greatest possible level of independence and stability. The Elder Care Plan:

  • Specifies local resources, programs, services, and supports required to meet the needs identified in the assessment
  • Identifies procedures to be used in an emergency
  • Focuses on types of assistance the elder needs to optimally function and remain independent as possible
  • Considers near term options as well as longer term strategies
  • Includes treatment options, referrals, and estimates of resources required
  • Includes options in all areas of elder’s environment
  • Lays out details for placement options in retirement centers, assisted living or skilled nursing facilities
  • Considers availability of local resources
  • Provides cost estimates for each alternative

Implementation

After your approval of the care plan, Aging Options begins implementation. We make connections with the best care suppliers and oversee their work. We make arrangements for all services, coordinating, facilitating and implementing every action item to create an immediate positive impact on the elder’s quality of life.

  • Make arrangements with facilities, caregivers, physicians, therapists, and other professionals to achieve the goals of the plan
  • Coordinate with agencies and staff to maximize the quality and efficiency of care
  • Facilitate communication between elder, family and physicians, and care givers
  • Help file insurance forms, assist with record keeping and bill payment
  • Assist in transition to alternate living facilities
  • Provide a local surrogate for a family living remotely
  • Facilitate expedited delivery of health equipment
  • Oversee installation and monitor Lifeline emergency notification equipment
  • Set up Internet access for elders to increase communication with family and friends

Advocacy

Your Geriatric Care Manager advocates for the elder to maximize well being, dignity, and quality of life, serving as family surrogates for children who cannot assume the role themselves. In the advocacy role, your GCM performs the following functions:

  • Advocates for quality, cost-effective and accessible care
  • Facilitates the acquisition of care resources
  • Coordinates the management of care facilities, nursing staff and other caregivers
  • Attends physician appointments to help the elder understand diagnosis and treatment options
  • Attends legal and financial conferences (along with legal members of the J&N team) to represent elder’s interests
  • Investigates alternate living facility cost / value
  • Advocates for the hospitalized elder and family
  • Assists as a family surrogate for elders in nursing facilities

Monitoring

Your Geriatric Care Manager monitors the elder’s well-being, programs and services for appropriateness, quality and satisfaction. We assure that the elder doesn’t receive less than needed or pay for more than required. Monitoring services include:

  • Regular visits to elder’s home or nursing facility
  • Crisis management on a 24×7 basis
  • Supervising and monitoring in-home caregivers
  • Responding to elder’s changing needs
  • Monitoring the quality and cost effectiveness of care
  • Providing regular updates for family and suggestions for change
  • Providing friendly visitation to minimize isolation – a “familiar” face

Re-Evaluation & Plan Updates

Things change. That’s why every Total Elder Care Solution includes regular reassessment and reevaluation to help you respond to the changing needs of your loved one. Services include:

  • Counseling elders and family during life transitions
  • Reassessing a client’s needs after a change in health condition or circumstances
  • Acting as a family surrogate to assist extended family living far away
  • Working with retirement homes, skilled nursing facilities and hospitals to assure a consistently high quality of care
  • Assistance in obtaining emergency services
  • Assuring that advanced directives are respected