Aging Options

Returning Home After A Hospital Stay

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Mary Lynn Pannen, RN, BSN, CCM

President, Sound Options, Inc.

Let’s face it; older adults want to stay at home as they age. When challenged with a crisis or just normal aging deterioration, family members often do not know where to go or where to start planning the care for an aging parent. This article will discuss common sense solutions to setting up a team that not only provides the desired home care but also support for the family and other members of the care team. Mildred has lived in her own modest home for over 50 years. She knew every inch of this home which was critical as she was had advancing macular degeneration and now she was legally blind. Her husband Art recently died which left her family struggling with how to help mom. Mildred had always told her family that the only way she was leaving her home was feet first. The family assured Mildred that they would do everything to keep her at home. Of course they understood that their father not only had been the eyes for their mother but also made the meals, did household chores, went grocery shopping and was the transportation to their medical appointments. Mildred was depressed and fearful. She did not want to loose her independence but realized her need for some help.

With her sight worsening, she knew she could not even go down into the basement to do the laundry. Her two daughters were worried about her and yet they could only help Mildred on weekends as they all had jobs and families to tend to. This is not an unusual situation. Mildred is now vulnerable. Avoiding a crisis is essential to her stability. So where does the family go from here? The following are eight common sense steps to take:

First and foremost, GET ADVICE.

Do not go on the Internet or ask your neighbor for advice. You will quickly confuse yourself and realize the learning curve is steep. Go to experts who are knowledgeable in geriatrics. Hire a Geriatric Care Manager! A Geriatric Care Manager (GCM) is a professional who can quickly assess your individual eldercare situation and arrive at a customized plan that will save you time and money. It is highly recommended to hire a Registered Nurse (RN) with a BSN or a Master’s Prepared Social worker (MSW) who understands the holistic needs of older adults. These professionals also understand local eldercare resources and how to navigate the health care system. They will be strong advocates for the older adult, objective in putting a plan in place and supervising the care in the home. Lastly, the geriatric care manager offers empathy and education to family members. This service is a fee for service model. It is important to understand the fee structure and how the billing works. Some companies have many care managers and others are a solo practice. The best choice is a company that has many care managers as they have routine care conferences and thus you as the customer can have the benefit of their collective wisdom and talents.

Consult with the Expert/ Have a Family Meeting.

Helping an older parent is a family affair. All families have their own abilities and skills that they bring to helping an elderly parent. Once you have selected the Geriatric Care Manager, you should consult with him/her or bring all the appropriate family members together for a meeting. The Geriatric Care Manager should lead the family meeting so as to avoid difficult family dynamics and to move the process forward efficiently. The meeting should remain focused on the care for Mom or Dad. If the parent is present, honor their wishes. Or if they are unable to participate, look at documents which may explain their wishes such as a Living Will or a Durable Power of Attorney. If families do not have these, they may have to rely on past conversations with their parents.

Families may meet in person, on a phone conference or meet via e-mail. It is important for all members to be honest about what they can or cannot contribute to a plan. Having time limits to the meeting, goals, expected outcomes and a specific plan are all crucial to moving forward. The Care Manager will educate the family on resources and what to expect when home care is in place. The care manager then will write up the plan detailing what members agreed to do, who will be the family contact person and how often the families will receive care reports from the care manager. If the family is in the middle of an Elder care crisis, then taking time for a family meeting might not be reasonable. The family meeting might come after the actual home care is in place.

Evaluate needs and Set up a Plan

In order to give the best recommendations for your elder’s care, the Geriatric Care Manager must evaluate the older adult in his/her own home. The care manager will look at your loved one holistically considering what is best for them at that moment. After gathering the information from the older adult, you, the family, and other health care professionals, a plan is written with recommendations that are customized to the exact needs of your loved one. This plan is a roadmap that should be implemented with the idea that the facts can change quickly in this older population and thus the plan may need to be altered. The care manager will implement the home care plan and bring in resources which will make the person safe and content to remain at home.

Put an Integrated Team in the Home

Finding the right person to take care your parent in the home can be another challenge. Do not try hiring a nurse’s aide on your own. Rely on agencies that conduct national background checks, supervise, train caregivers, do payroll, are licensed and bonded and are in partnership with the care manager. There now are agencies that use both the professional care manager and the caregiver as an integrated team in the home. This approach allows for more service to your loved one and it helps you, the family member, have peace of mind. While the care manager is looking at the big picture, the day to day caregiver will provide companionship, assistance with personal and household tasks, transportation and so much more. With the integrated team, as you’re loved one deteriorates, the care manager can train the caregiver for more sophisticated care needs while keeping the team in place. Together, the care manager and caregiver are providing a much higher level of service and concentrated attention to your elder’s needs.

Evaluate care, be flexible and value small gains

All along the way, the care manager will evaluate the elder’s plan of care, its relevancy, quality, efficiency and cost. Is the older person stable? Have they stayed out of the hospital? Do they think their life is better than before the home care began? Have the services been of value to the family? Are the family’s expectations met? Both the professional and the family should remain flexible as changes occur. Going on this care journey with the older adult and offering them support, understanding and kindness is essential to providing quality of life.

Establish a long term strategy

After the initial crisis is over and the home care plan is in place, it is time to look ahead. Although we cannot predict the future, we can predict certain outcomes based on knowledge about geriatric care. The care manager should meet with the family and talk about a long term strategy. Many questions need to be considered. How many resources will mom need as her care needs increase? What kind of equipment will she need? How many more hours of caregivers will she need? Are end of life arrangements in order? The care manager can also educate the family members on what to expect in regards to disease entities, medications, what to expect during the last days of life and so on. Having these conversations can really help the family have a positive experience and feel a part of the care.

Mildred’s family hired a Geriatric Care Manager and when it was determined that a non-medical caregiver was necessary to keep her safe in the home, they brought in a lovely caregiver. This integrated team of the GCM and caregiver together were able to offer a high level of care and quality of life. The family felt satisfied that they were indeed helping their mother the best they could. And Mildred reported that she too was satisfied and content to be at home.

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