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Senior Home Care Services of Sarasota – Care Management

What is Geriatric Care Management?

Geriatric care management (also known as “senior care management”, “elder care management” and “professional care management”) is the process of planning and coordinating care of the elderly (and others with physical and/or mental impairments) to meet their long term care needs, improve their quality of life, and maintain their freedom and independence for as long as possible. It entails working with persons of old age and their families, as well as disabled persons, in managing, rendering and referring various types of health and social care services. Geriatric care managers accomplish this by combining a working knowledge of health and psychology, human development, family dynamics, public and private resources and funding sources, while advocating for their clients throughout the continuum of care.

According to the National Association of Professional Geriatric Care Managers (http://www.caremanager.org) care management “is a holistic, client-centered approach to caring for older adults or disabled persons.  The goal is to improve the client’s quality of life and reduce family stress through:

  • Assessment and monitoring
  • Planning and problem-solving
  • Education and advocacy
  • Family caregiver coaching

Geriatric Care Managers assist in a variety of areas, such as:

  • Housing – helping families evaluate and select appropriate level of housing or residential options
  • Home Care Services – determining types of services that are right for a client and assisting the family to engage and monitor those services
  • Medical Management – attending doctor appointments, facilitating communication between doctor, client, and family, and if appropriate, monitoring client’s adherence to medical orders and instructions
  • Communication – keeping family members, as well as chosen professionals, informed as to the well-being and changing needs of the client
  • Social Activities – providing opportunity for client to engage in social, recreational, or cultural activities that enrich the quality of life
  • Legal – referring to or consulting with elder law attorney, providing expert opinion for courts in determining level of care
  • Financial– may include reviewing or overseeing bill paying or consulting with accountant or client’s Power of Attorney
  • Entitlements – providing information on Federal and state entitlements; connecting families to local programs, including Medicaid, VA benefits, and more…
  • Safety & Security – monitoring client at home; recommending technologies to add to security or safety; observing changes and potential risks of exploitation or abuse

Local, cost-effective resources are identified and engaged as needed.

A care plan tailored for each individual’s circumstances is prepared after a comprehensive assessment. The plan may be modified, in consultation with client and family, as circumstances change.”

In summation, the goal of Care Management is to achieve an optimal level of wellness and improve coordination of care while providing cost-effective, non-duplicative services.

Why is all this necessary?

Let’s face it, if you’re like most people over 65, you’re managing at least one chronic condition, you’re taking several different medications every day, you’re seeing several healthcare professionals and you use more than one pharmacy. Add in the fact that you have to weigh the amount of care you can receive against your other financial obligations, and that applying for the help you need, whether you’re a veteran applying for the VA Aid and Attendant benefit or a Medicaid recipient, can be an overwhelming and daunting maze of forms and documents – and the very real value of a professional care manager advocating for you and your needs quickly becomes evident!

Hiring a care manager can also be particularly of use when conflicting viewpoint regarding the care of an aging family member emerge within a family. The insight of an unbiased and professional care manager can ensure the appropriate care is being given, and at optimal levels, and put a rest to the uncertainty and conflict within the family. Your care manager will act to ensure that the highest quality of life is being achieved through a comprehensively managed care plan developed specifically for your loved one.

Assessment and Planning…

A care plan tailored for specific circumstances is prepared after a comprehensive assessment has taken place, and is continuously monitored and modified as needed. A comprehensive geriatric care assessment is thorough and can take anywhere from 2 to 5 hours in length, this of course is broken down into 2 or 3 assessment visits with the patient and/or their family members. The comprehensive assessment is really a compilation of smaller individual assessments with the first one being a primary intake assessment which includes demographic type data as well as a health history, social history, & legal/financial history. From there, a medication profile assessment is included, as well as an assessment of ADLs (Activities of Daily Living) and IADLs (Instrumental Activities of Daily Living). In addition other assessments may include; falls risk assessment, home safety assessment, nutritional assessment, depression assessment, pain assessment, cognitive assessment, balance assessment, and gait assessment (ability to walk). If the comprehensive geriatric care management assessment is being conducted by a Registered Nurse, as is the case with Care Providers at Home, then a physical assessment may be conducted, including the recording of vital signs such as temperature, pulse, respirations, blood pressure, oxygen saturation, and sometimes FBS or RBS (Fasting or Random Blood Sugar) checks for diabetics.

The Role of Geriatric Care Managers

Geriatric care managers typically have prior training in nursing, social work, gerontology or other health service areas. In our case, administrator, Jim Grimes, has prior training as a state-licensed RN, a state-certified professional guardian, and is currently undertaking additional  care management training at the University of Florida.

Professional care managers help individuals, families and other caregivers adjust and cope with the challenges of aging or disability by:

  • Conducting care-planning assessments to identify needs, problems and eligibility for assistance;
  • Screening, arranging, and monitoring in-home help and other services;
  • Reviewing financial, legal, or medical issues;
  • Offering referrals to specialists to avoid future problems and to conserve assets;
  • Providing crisis intervention;
  • Acting as a liaison to families at a distance;
  • Making sure things are going well and alerting families of problems;
  • Assisting with moving their clients to or from a retirement complex, assisted living facility, rehabilitation facility or nursing home;
  • Providing client and family education and advocacy;
  • Offering counseling and support.

Depending on the country and health care organization, professional fees for the services of geriatric care managers may be billed privately on a fee-for-service basis.

For more information on geriatric care management, please call to speak directly with our Care Manager at (941) 685-3838.

Care Providers at Home’s Care Manager, Jim Grimes, is a state-licensed Registered Nurse & Professional Guardian, with 30 years in business to add. Recognized with multiple awards from the University of South Florida, College of Nursing, Jim is now furthering his education in Care Management at the University of Florida, Gainesville.