It takes a team effort to keep elderly patients out of the hospital

Geriatric case managers coordinate all aspects of care

Do you have an elderly client who, despite your best efforts, is in and out of the hospital and emergency department, has problems with medication compliance, and otherwise seems incapable of understanding or following his or her recommended treatment plan?

If this sounds familiar, it may be time to urge the family to call in a geriatric care manager, a specialist who can coordinate all aspects of a senior's care.

"Hospitals see patients who come and go like there's a revolving door. This is when patients need someone in the community to find out what is going on and to make sure the senior gets the care he or she needs to stay as healthy as possible," says Pearlbea LaBier, MSW, ACSW, owner of Elder Options, a Washington, DC, geriatric care management firm.

Seniors often have far more problems than just the illness or condition that brings them to the attention of a case manager in the hospital or managed care arena. There often are a multitude of issues, some of them outside the realm of health care, that can affect an elderly person's health and exacerbate their chronic illnesses, resulting in hospitalizations and emergency department visits.

"Elderly patients often have memory loss, confusion, disorientation, as well as medical conditions which cause functional problems and changes in mental status," says Susan Fleischer, LCSW, DCSW, CSWM, CMC, chief operating officer for Rona Bartelstone Care Management and Home Healthcare in Fort Lauderdale, FL.

When they get home from the hospital, they may neglect their personal hygiene, fail to eat regularly, or get confused about the multiple medications they take. They may have mobility problems and be at risk for falls in the home.

All of these problems, if left unchecked, can result in additional hospital admissions and poor outcomes.

"Managing the care of an elderly person takes a team effort. In addition to the physical illness, seniors often are confused, depressed, at risk for falls, and have trouble managing the activities of daily living," asserts Beverly Bernstein Joie, MS, CMC, president of Elder Connections in Philadelphia.

Geriatric care managers work with hospital case managers and social workers, with insurance case managers, physicians, and other health care providers, and community agencies as well as attorneys, financial planners, and life care planners.

"We coordinate and monitor services from all different providers. We communicate with everyone and ask questions to make sure that our clients are going to be safe," Joie says.

Managing the care of an elderly patient with a chronic disease involves far more than reminding them to get their hemoglobin A1C levels checked or to weigh themselves every morning. It means understanding the senior's stage in life, looking at their family, friends, their entire support system, and everything that is going on at home, Fleischer says.

Hospital case managers and social workers and disease management case managers can help their elderly clients avoid hospitalizations if they step in and alert the family when the senior is not progressing well, says Amy Siegel, RN, CCM, CRRN, owner of Advocare Geriatric Care Management of South Florida, with headquarters in Fort Lauderdale.

"If they are willing to go that extra mile and give their patient's family the name of a geriatric care manager, they can help the patient after discharge and prevent exacerbation of the patient's condition," she says.

After hospitalization, seniors may be bombarded by calls from home care, equipment companies, physical therapists, occupational therapists, and other vendors who adds to the anxiety the patient already is feeling, Siegel says.

Discharge planners and case managers often arrange for durable medical equipment to be delivered to a senior citizen's home, but they aren't on the scene when it arrives to make sure the senior understands how to use it.

"Following up on seniors after a hospital stay can prevent a lot of recurring hospital visits," Siegel says.

What typically happens after a senior is hospitalized is that post-acute services come in segments, she adds.

"Everybody has their job to do and their focus. It becomes very chaotic and confusing, especially for someone who is very ill. There needs to be a gatekeeper, someone whether it's a care manager or a family member, who understands how all the pieces fit together and who can ensure that everything the senior needs is being done," Siegel says.

Patients are being discharged from the hospital earlier than ever, and they're not always that well or lucid when they go home.

"Without a care manager, there are all these fragmented pieces that confuse them, and often things they need fall through the cracks," Siegel says.

Medication management and medication safety issues are other areas where having a geriatric care manager on the scene can be helpful, Fleischer points out.

"Seniors leave the hospital during which their medication regime was changed. When they get home, there's the medication they took prior to hospitalization and they take that as well, which can cause severe problems," she says.

Even if the hospital case manager writes out detailed instructions about medication, there's no guarantee that the senior is going to read and follow them.

"Take any 80-something person who has just gotten out of the hospital, throw in multiple medications and a confused mental state, and that doesn't make for the strongest outcome without somebody in there making sure that the senior understands what he or she is supposed to do," she says.

In the hospital settings, case managers should make sure the seniors and caregivers understand the instructions. Medication and other instructions should be written out for nursing aides who may care for the patient after discharge, Siegel says.

When elderly people are hospitalized, a geriatric care manager is able to work with the hospital discharge planner, the insurance company's case manager, and the physician to ensure that the patient has a safe discharge back to the community.

"If we look at care being on a continuum, our role is vital in helping the seniors maintain their independence, stay compliant with their treatment plan, and live safely so they aren't hospitalized," Fleischer says.

By going into the home, a care manager can assess exactly how a senior is living, whether there are safety issues, food in the refrigerator, heat, and electricity.

"There's so much information you can't get over the phone. Being on-site is critical to helping people in this age group," Siegel says.

During a home visit, a geriatric care manager will notice if the client has problems with self-care or if the primary caregiver is becoming stressed and call in help to make sure the caregiver doesn't become the patient.