June 1, 2006

Aging Connection

Care managers help guide older adults and their families

By Vivian I. Silva, Gerontologist
Special to the Times

A 75-year-old woman lives alone in her own home. She has had some falls and her son calls a care manager to discuss the mother’s future. Care managers know the resources in the community and establish relationships with service providers.

The son asks the care manager to visit his mother at home and suggests that this may be the time to put his mother in a safer environment such as a skilled nursing facility.

The woman has not felt well and appears unsteady on her feet. The care manager finds her willing to discuss the situation. The older woman states, “I’d like to stay in my own home.”

The above vignette is just one example of how a professional care manager can help a family dealing with aging issues. A home visit is the best location, if possible, for a meeting. Seeing a person in their home environment is the ideal situation. However, office consults and telephone calls are other ways to discuss the situation with the older adult or their family and/or caregiver.

Five basic components comprise the care management process.

Assessment
The care manager discusses financial status, health and environmental issues. Knowing if a support system is in place as well a person’s religious or spiritual affiliations offers a more complete picture of the elder’s world.

The family member or caregiver may identify a need whereas the older adult may not see the situation as a problem at all. The care manager’s objective assessment helps clarify what the needs are and presents possible solutions.

The older woman in the story above did not need a skilled nursing facility. She was alert, oriented and even though she had a few falls that doesn’t mean one needs 24-hour care. She was grieving and depressed. Her minister moved away and the son didn’t realize how important the spiritual connection and friendship was to her.

Care planning
After the assessment, the care manager develops a care plan that is affordable and realistic. This is a cooperative effort with all those involved.

After assessing that the older woman was not at risk for living alone and after eliminating any doubt of severe cognitive impairment, the next step was to provide a list of options to keep her safe in her home. Included on the care plan would be a call to the physician to see if a workup would show any medical reasons for the falls.

Other options discussed would be to use a walker, remove any loose throw rugs or extra clutter around the house and installing grab bars in the bathroom. In addition, talking to the new pastor at her church, seeking counseling and assessing for depression are other suggestions to list on the care plan.

Coordination
If it is appropriate, the care manager arranges the necessary services. Of course, one must keep in mind what would be the most appropriate services and the need to stay within the client’s budget.

Linkage to services includes using formal systems in the community as well as engaging family members and friends if willing.

In this case, the son and daughter-in-law took the suggestions from the care plan and agreed to follow up for her.
There was no more need for care management services.

Monitoring
The care manager tracks the services delivered and makes sure all is in order. As the older person’s needs change the care manager may need to modify the current services. The goal is to keep the client situation stable.

Termination
Client involvement can end at any time. The client can terminate the care management relationship. However, if all is in place and going well without any need for continued interventions or monitoring, the care manager can terminate the contract.

Vivian I. Silva, Gerontologist/ MSW is the director of Geriatric Advisory Program at Almaden Valley Counseling Service. The service educates and advises adult children and elders on aging issues and provides individual and family consultation. For more information call (408) 975-2988 or e-mail vivsilva@aol.com.