Critical Path Network

Geriatric CMs collaborate on discharge planning

Hospital-based nurses keep seniors home

When an elderly patient is hospitalized at Lee Memorial Hospital in Fort Myers, FL, the case managers on the unit may call in a geriatric care manager who already has been working with the patient and has additional information that will be useful in creating the discharge plan.

While many geriatric care managers are independent contractors, Lee Memorial has a hospital-based program, Senior Care Choices.

"As a part of the health system, we can help with the continuum of care and can coordinate care for the patient between the hospital and the home, and back again when necessary. As health professionals who visit the patients in the home, we can let the nurses and doctors know what the home environment is like and what the patients are like when they aren't in the hospital," says Dawn Moore, RN, one of three geriatric care managers at Senior Care Choices.

Senior Care Choices receives referrals from nurses, physicians, hospital social workers and case managers, family members, trust officers, attorneys, guardians, and senior organizations.

Like other geriatric care managers, Moore is paid by the patient or the family.

Senior Care Choices is a fee-for-service program. The fact that the care managers are hospital-based makes it possible for them to establish a close working relationship with the hospital staff that pays off when a client is hospitalized, Moore adds.

When a client is hospitalized, Moore often is part of the discharge planning team. She meets with the case managers, social workers, and discharge planners, and other members of the health care team at the hospital and gives them an accurate picture of the patient's home situation and other input that helps the discharge planning team save time and make sure that the patient can be discharged safely.

"We know all the little things that can make a huge difference in the discharge plan, like the home environment and the family dynamics. We let the hospital staff know who this is beyond being a sick person. We advocate for our clients and let them know what the person is capable of doing," she says.

Because hospital stays are so short and the post-discharge needs of the elderly often are so intense, it's difficult for the hospital social workers and discharge planners to get a handle on what the patient is going to need, Moore points out.

The geriatric care managers provide someone who is aware of the elderly patients' situations and who can work with the discharge planning staff to find the best discharge destination.

"When older people are in and out of the hospital and are trying to live alone, it's easy for the hospital staff to misinterpret how well someone is doing. Repeated hospitalizations may indicate to the social worker that they can't handle living on their own. We try to keep that from happening," Moore says.

For instance, some elderly patients who are hospitalized often appear to be helpless and confused although they were living independently with support in place and doing well at home.

"We really like to participate in helping make decisions about what happens after the patient is discharged from the hospital," Moore says.

When Moore is hired by a family to manage the care of a senior, she goes into the home and performs a detailed assessment, looking at medical issues, social issues, and what support systems the client has in place. She screens for depression and memory issues and makes sure that advanced directives such as power of attorney or health care surrogates are in place.

"We look at where their needs are, then sit down with the family or the client and family and review the needs, then come up with a plan to meet those needs," she adds.

For instance, an elderly client may need transportation to get to the doctor and the grocery store and need help with housekeeping chores. Or they may not be compliant with their medications and have difficulty paying bills.

"There's never a cookie-cutter solution. Every-body's plan of care is different depending on their needs, their personalities, and what they can afford," Moore explains.

Her goal is to do whatever is possible to keep the senior as independent as possible and to take care of any problems that arise before they become big problems. "Geriatric care management is often initiated when the senior citizen has a crisis. Our job is to prevent crises from happening and to keep our clients out of the hospital. It may be something as simple as helping the seniors find ways to be compliant with their medications or get their nutritional needs met," Moore says.

Many seniors living in the southwest Florida area are from other parts of the country and retired to southwest Florida, leaving their families hundreds of miles away.

About 90% of Moore's clients have families who live out of state.

The difference between a geriatric care manager and a home health nurse is that the care managers have more time and availability to focus on the whole person and not just the medical issues. The time spent with the client is not restricted by insurance regulation or reimbursement concerns, she says. "Advocacy is a huge part of what we are doing. We coordinate services, manage services, and make sure that whatever services are in place remain appropriate. We are a bridge between the family and the senior. We can be their eyes and ears," she says.

For more information, contact: Dawn Moore, RN, at e-mail: