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December 2005
In this Edition:
Not Home for the Holidays? Tips to Avoid the Holiday Blues
All Clients and Staff Safely Cared for During and After Wilma
Assuring Implementation of Your Plan of Care in the Home:
Private Care Management as a Resource
Not Home for the Holidays? Tips to Avoid the Holiday Blues
The holidays can be a difficult time, especially for those living far from family and those whose frailty
limits their participation in holiday preparation and festivities. Also, caregivers may feel the loss of a
loved one or feel the losses of those for whom they care.
You can turn burdens into blessings by creatively looking at how we handle the holiday season and its many
layers of meaning. Here are some tips to help you reduce stress and actually enjoy the season.
- We are usually our own worst critics, so be gentle on yourself.
- Take time out to do something special for yourself, even if it is as simple as a quiet cup of coffee (decaf, of course!) with a friend.
- Share your holiday preparations with others. If you are preparing meals, decorating, or wrapping and sending gifts, involve other "volunteers" in the process. You will increase the fun and reduce the time pressures.
- Don't try to be perfect! You don't always have to have the perfect gift, dinner or dress to be the perfectly wonderful person you are. Remember, we are human beings, not human doings.
- If you're sad, express it. If you feel like crying over losses or changes, cry. Share your feelings with those who are close to you. You can remind others that you don't want them to "fix" anything; you just want them to listen and be with you. And if someone else is sad and needs a shoulder, remember to listen and don't try to "fix" it. They're also entitled to their feelings, and there is nothing better than a compassionate, listening ear to help people move on.
- Create a new tradition. Try giving something personal that is part of who you are - an old photo restored and framed, a favorite old family recipe in a new recipe box or a family keepsake. One of our clients past along her old family linens to grandchildren and suddenly she was part of a family celebration from 500 miles away!
- If family are coming from out of town and they have not seen the daily changes in a parent or other loved one, give them some preparation for what they might expect. This needs to be done gently so that realistic expectations are created without additional anxiety.
- When a loved one has cognitive losses, remember to talk them through each event and give permission to withdraw if they become overwhelmed or agitated. The quality of the visit is more important than the quantity of the visit.
- Discuss plans and expectations ahead of time. Don't assume that everyone knows your traditions, preferences or schedules. It is better to give visitors and loved ones more information about your plans, so that everyone can enjoy themselves with few or no surprises.
- Slow down! Impossible you say, but just try it. Take one morning to linger over the paper or your current book. Spend a day in your PJs as part of your caring for yourself. The world really won't end if you give yourself permission to breathe!
All Clients and Staff Safely Cared for During and After Wilma
"All our clients and staff came through the storm well because of preparation and follow-up that enabling
them to be cared for in an efficient and effective manner," said Rona Bartelstone, CEO of Rona Bartelstone
Care Management and Home Healthcare.
"As usual, we saw some heroic caregiving efforts by both our care managers and our home care workers.
We are infinitely proud of the work that we do to help elders, the disabled and their families weather
the most trying of circumstances - even hurricane Wilma!"
For Rona Bartelstone, hurricane planning begins every year in May. We review last year's plan and update
it according to lessons learned. Our care managers and the home healthcare team work with every
client in advance to have an emergency preparedness plan that includes an alternate living situation
(a shelter, residential care facility, nursing home or hotel) if they are in an evacuation zone and
items needed, such as food, water, medications and emergency lighting.
At the time of a hurricane warning, we contact all clients to assure storm readiness. We also contact
our staff to assure that they have made their preparations. For staff staying with clients, we contact
the clients' families to see that they have a plan that assures their safety.
Despite the best plans, there are always unanticipated needs during and after a storm. Here are some
stories that illustrate the dedication, creativity and team approach of our valiant staff and the care
they provided to our clients and their families!
Evacuating After the Storm
Mr. E is 95 years old and lives in his own condominium. He has around-the-clock care because of his
need to be on oxygen and to have a hospital bed and urinary catheter.
Although he was not in an evacuation zone, care manager Nina Rothstein received a call from his family
shortly after the storm; Mr. E needed to be relocated immediately because his building had extensive
roof damage and was no longer a safe place to live. Nina worked with Mr. E's family, and within 24
hours an appropriate assisted living facility was found that could accommodate his needs.
With the help of the home healthcare staff, Nina moved Mr. E into the facility and arranged to have
his oxygen and hospital bed delivered. Nina oriented him and his staff to the new living situation and
provided constant communication to his family.
This team approach involving the care manager, the home healthcare staff, the family, the facility,
a durable medical equipment company and his health provider assured Mr. E's wellbeing. The fact that
the team was in place in advance of the need made the transition efficient and effective.
Medical Advocacy is Always Important
Mr. G is an 89-year-old widower who has lived in his apartment for many years. He has many friends
in the building who provide social and emotional support. As part of our telephone follow-up to clients
after the storm, care manager Sandy Goldberg called Mr. G.
When she wasn't able to get Mr. G on the phone, she became concerned and called his close friend in the
building and asked her to check on him. Unfortunately, the neighbor found Mr. G on the floor of his
apartment.
The neighbor called the emergency medical team (EMT), which came and found that his vital signs were ok.
He was reluctant to go the emergency room, so they bandaged his head and left.
When Sandy called back, the neighbor told her about Mr. G's fall and the EMT visit. The neighbor also
reported that Mr. G was so weak that he could not walk or use his arms to help himself off the floor.
Sandy instructed the neighbor to call the EMT back and to get her on the phone when they arrived. As a
nurse care manager, Sandy was able to explain to the EMT that Mr. G was strong and ambulating just the
day before and that his weakness was an indication that something medical was happening. She had him
transported to the emergency room of the local hospital.
At the hospital, it was determined that Mr. G required acute care. Within a few days, the hospital
wanted to send Mr. G home, despite his continuing weakness and the lack of electricity at his home.
Again, Sandy became his staunch advocate and insisted that he be admitted to the rehab floor of the
hospital until it was physically and environmentally safe for him to go home.
Now that the crisis has past, Mr. G is making a good recovery at home with appropriate supervision. Had
the care manager not been a strong advocate for appropriate medical care, Mr. G might not have survived.
Going the Extra Miles When It Really Counts
Three days after Wilma, Barbara Harris had already been out to see several of her most frail clients,
despite hazardous road conditions, no power in most places and gas becoming scarce.
As she was ending her day of visits, she got a call from Mrs. B's son, who was concerned about the way
his mother sounded on the phone. (Mrs. B had been in the hospital for treatment of her chronic lung
condition and infection and was discharged the day before the storm.)
Barbara was able to see Mrs. B, but it was after 5 p.m., so she was not able to speak to the doctor.
The next day, her symptoms worsened, and Mrs. B was admitted to the hospital by her pulmonary specialist.
The hospital was 25 miles from Barbara's home, and she was out of gas. Barbara and Mrs. B's son decided
to rent a car that had gas, so she could take Mrs. B to the hospital and stay with her through the
admission process.
In addition, our home care coordinator found an aide who still had gas, enabling someone to stay with Mrs.
B so that she would not be frightened or disoriented. Again, the teamwork of the family and the doctor -
together with some creativity - helped meet the needs of the client and assured a positive outcome for
the elder!
Even Pet Care is Important to a Client's Wellbeing
Mrs. L is bed-bound and on a feeding tube, so she must be evacuated to a skilled nursing facility in the
event of a storm. Although her care had been planned for long in advance and she was safely moved to the
appropriate facility, she was despondent that her cat could not accompany her.
So care manager Barbara Harris took the cat home with her. She saw Mr. L the day after the hurricane
(despite all of the debris, the gas shortage and no traffic lights) and gave her pictures of her beloved
cat, so she wouldn't be lonely or concerned about her pet's care. Now Mrs. L has returned to her home and
is thriving with the help of her long time aide, the friendship of the Barbara and the love of her cat.
Assuring Implementation of Your Plan of Care in the Home:
Private Care Management as a Resource
When you have a population that is heavily weighted with older adults and patients with chronic illnesses,
it is difficult to assure that the physician's plan of care will actually be implemented in the home setting.
This often leads to mismanagement of health care needs in the home and the increasing incidence of excess
disability and repeat healthcare crises within your patient census. This lack of control in the home
environment can be both frustrating and costly for physicians, health plans, hospitals and patients.
Private care management is a service that has evolved over the past twenty five years to address just
these issues and to help the healthcare system better meet the needs of patients and providers. This is
achieved by following the patients across multiple settings and assuring the coordination of care and
communication among the various providers.
Differentiating Care from Case Management
Historically, case management has been a function of third party payers to provide financial gate keeping
services in parallel to healthcare provision. This was rooted in a medical model of funding that was
triggered by an acute medical episode requiring intense short term medical care, rehabilitation and a
return to function. Because there was an expectation that the individual would regain all or most of
their prior functional status, there was little need to focus on the broader psycho-social-behavioral
issues in the person's life.
However, as medical advances have made most illnesses into chronic diseases, this combines with the
growing age wave to make a more comprehensive, individualized and consumer centered plan of care an
essential component of successful healthcare delivery. It becomes more important to treat the whole
person and his/her support system in order to have a compliant patient who is a partner in care.
Private care management, therefore, evolved from this more comprehensive perspective of partnering
with the patient, the caregivers, community resources and legal and financial advisors to address the
full spectrum of needs of the care recipient. This bio-psycho-social-environmental approach is more
appropriate for an aging population with chronic care needs who often cannot advocate for themselves.
Assistance for decision making about end of life issues, care alternatives and surrogate care givers
may also trigger care management. Pro-active intervention by a care manager in partnership with the
care recipient and the family can lead to better compliance, intervention before a crisis and
stabilization of the physician's plan of care.
Physicians and Private Care Managers: A Natural Partnership
Care Managers have been relatively successful at partnering with attorneys, trust officers, assisted
living facilities, public and private agencies to meet the needs of older adults and persons with
chronic illnesses. It has been more challenging to partner with physicians and hospitals because
there is not a funding stream through traditional Medicare or HMOs for a bio-psycho-social approach
to care management. However, families are willing and able to pay for services if it saves them time
away from work and the travel expense that long distance caregivers experience.
Increasingly physicians and discharge planners are aware of the fact that patients cannot be responsible
for the implementation of a plan of care without assistance from a family or professional caregiver.
Often the chronic nature of care exceeds what a Medicare home health agency can do within their limited
episode of care. It is also beyond the skill and training level of a privately hired aide. These tasks
include supervision of in home staff, medication management, assuring that follow up medical appointments
are kept, providing emotional support for dealing with losses, environmental safety to prevent falls,
reviewing routines for appropriate nutrition and hydration, relating to out of town families about the
needs of the care recipient, assuring the use of community services (such as VA benefits, day care and
meal programs), assuring that finances and legal issues are handled properly by professionals, and the
coordination of all services to avoid overwhelming the patient.
One of the many benefits of working with a care manager is that s/he will be able to see changes in the
patient and help to assure medical intervention prior to a crisis. With regular visits from a professional
in the home, Rona Bartelstone Care Management has experienced many situations in which there is health,
mental health or functional changes that are not reported by the elder, but that are indicative of the need
for immediate medical or social intervention. The care manager can alert the physician and the family to
assure that appropriate care is provided and the crisis averted. When the crisis does come, the care manager
can assure that family is kept informed, and that medical care is provided in a timely manner.
Care managers and physicians together can provide a more comprehensive service to our elders than either
can achieve alone!
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