Geriatric Care Management: Creating a Plan and a Team

Geriatric Care ManagementGeriatric care management is the process of assessing a senior’s needs for medical and personal services, developing a care plan, coordinating services, monitoring outcomes and adapting services to changing circumstances.  Typically the geriatric care management team is led by a geriatric care manager who is a qualified nurse or social worker.   Every senior and family situation is different, so the make up of the geriatric care management team will vary.  The goal, however, is the same; to ensure your loved one receives the most appropriate services and support while honoring the individual’s autonomy and self-determination.

The Care Plan

At the end of the day the goal is to help clients live as independently and safely as possible.  The care plan is the service and support road map and should include specific recommendations to meet the client’s medical, psychological, functional and social needs.  You should find specific actions for addressing immediate problems (e.g. install grab bars and a shower seat in the bathroom),  strategies to monitor the client’s status (e.g. companion services 3 days a week to supplement family visits on weekends),  and options for future or anticipated problems (e.g. become familiar with local assisted living communities.)  A critically important question to consider, “what happens when my mother’s needs change?”

Members of the Geriatric Care Management Team

As mentioned a geriatric care manager (nurse or social worker) will typically take the lead on behalf of the senior and family.  Other core team members:

The Senior Client.  When possible, senior clients should be active members of the team.  Make sure your loved one shares likes, dislikes, concerns and goals.  Involvement is important to a successful outcome.

The Family. The geriatric care management team will look to family members for information especially in those instances when the client is unable to make wishes known.  Be sure to share your experiences, concerns and goals, and don’t be shy about asking questions.

The Primary Care Physician. The client’s personal family doctor is an important member of the team with knowledge of the individual’s medical history.  In some instances accessing other medical services may require an order from the primary care physician.  Make a master list of all medications.

Other Team Members

Other team members may include but not be limited to the following professionals whose assessments and recommendations can be included in the care plan as background information and/or action items:

  • Audiologist - hearing
  • Optometrist - vision
  • Dentist - dental
  • Podiatrist - feet
  • Pharmacist - medications
  • Nutritionist (registered dietitian) - appetite, weight loss, difficulty chewing
  • Physical Therapist - movement dysfunction
  • Occupational Therapist - activities of daily living
  • Speech Therapist - speech, language and may include swallowing

Important Services the Team May Need

The geriatric care manager should have information about and connections to an array of community-based professional services that may include, but not be limited to:

  • Adult Day Care - social with meals, recreation, some health-related services
  • Adult Day Health - social activities with more intensive health and therapeutic services
  • Specialized Adult Day - for those with specific care needs such as Alzheimer’s disease
  • Elder Law Attorneys - attorneys with expertise in areas of the law related to aging and services tailored to seniors and their families
  • Home Care Services - non-medical such as cleaning, laundry, meal preparation, transportation
  • Home Health Care - licensed health care professionals such as nurses and rehab therapists
  • Home Remodeling Services - adapting existing home structure
  • Hospice Services - specialty end-of-life services
  • Mental Health Services - public or private evaluation and treatment
  • Mediation Services - conflict resolution
  • Medication Dispensing Systems - in-home automated medication management
  • Motion Sensor Systems - in-home monitoring movements for safety
  • Respite Care Services - intermittent or regularly scheduled caregiver relief
  • Safety Alert Systems - medical alert, fire, home intrusion, quick response systems
  • Senior Care Options - assisted living, adult family homes, continuing care, retirement communities, nursing homes
  • Senior Move Managers - downsizing and relocating
  • Telehealth Systems - home-based computer systems for monitoring vital signs
  • Transition Services - estate sale, garage sale, yard sale and downsizing
  • Transportation Services - access to public or private services

Ask for assistance when interviewing and hiring these and other community-based services.

A Dynamic Process

Geriatric care management is a dynamic process with many moving parts.  The physical and emotional health of both client and family, the living situation and finances can be in constant motion.  “Adaptation” is the watchword.  While a plan may be developed, agreed upon and even initiated, a sudden change in your loved one’s health may call for a revised plan.  Embracing the changes that come with aging, keeping a positive attitude and asking for help from the geriatric care management team will make your journey and any detours easier for everyone involved.

Written by senior care expert Peg Witham