Windward Life Care’s professional Aging Life Care Managers provide an array of services that benefit clients and their families. One particularly important function is assisting clients and their support systems in managing medical conditions and related problems. This includes helping clients and their families navigate through often stressful and confusing hospital visits, whether the visits are routine or urgent. Care managers like Windward’s Terry Ehlke, RN, BSN, CMC, serve as the client’s primary advocate to facilitate the entire process. Terry took some time out of her busy schedule to answer questions about some of the essential services a care manager provides at such critical moments in a client’s care.

Terry Ehlke, RN
Clinical Services Manager
Windward Life Care

How can Aging Life Care Managers help when an older or disabled adult is hospitalized?

Care managers function as patient advocates, making sure the client is cared for properly during hospitalization all the way through discharge. Care managers work closely with the client and hospital team to ensure everyone understands the history and special needs of the client, any unnecessary trips back are avoided (such as for tests that can be handled during the current visit), the client is safely discharged, and adequate discharge instructions are provided to the client and caregiver. A care manager can also step in with any appeals to pause or slow down the discharge process if need be. Often clients don’t realize they can say “no,” so they just go along. The ultimate goal is for clients to experience the safest and most effective and efficient hospital stay possible.

What are the risks when the hospital says it’s time for a patient to be discharged?

Unfortunately, the discharge process can often be too fast and disorganized. Without any standard of care for hospital discharge in place, every hospital does their own thing. Hospital staff are under great time pressure and can rely on “cookie cutter” discharge plans that don’t account for the client’s unique circumstances. The very real situation at the client’s home is often overlooked, so failures stemming from not considering certain bigger-picture issues are common. Elderly clients especially are very medically fragile. In addition, communication and referral delays can lead to unsafe situations at home and treatment delays. Instructions to the patient regarding follow-up care, if even provided, can be rushed and inadequate. This is particularly dangerous in the case of a new diagnosis for diabetes or congestive heart failure. There is a significant risk that problems that could have been easily prevented through a better discharge process will lead to readmission.

Why is preventing readmission such a big deal?

I recently read a study that revealed up to 27% of rehospitalizations were preventable. While it’s true that many readmissions are simply not avoidable, medical issues that are not resolved prior to discharge or failures in the transition to home can often result in an otherwise unnecessary return to the hospital or emergency department. Readmission has a huge impact on the client’s quality of life and safety. Each hospital visit poses that much more exposure to potentially lethal complications (medication errors, hospital-acquired infections, blood clots, etc.) while putting added stress on the client who is once again away from the comforts of home in an unfamiliar environment. Worsening cognition, including delirium, can result from being in the hospital environment. Ultimately, readmission delays recovery, possibly introducing new complications.

Who is most at risk for recurring hospitalizations/readmission?

There are myriad factors that increase the risk of repeat hospitalizations. These include taking certain medications, such as antibiotics, glucocorticoids, anticoagulants, narcotics, antipsychotics, and antidepressants to name a few, as well as certain chronic health conditions, like advanced chronic obstructive pulmonary disease, diabetes, heart disease, stroke, cancer, and depression, among many others. Prior recent hospitalizations and premature discharges also increase risk, as does low health literacy, a limited social network, and low socioeconomic status.

A key advantage of working with a care manager is that we have detailed knowledge of a client’s daily life, health, diet, medication regimen, and other circumstances that can impact his or her health and well-being when it comes to hospital readmission.

Medications can be confusing and the risks of taking them incorrectly are high. What can families do to help reduce errors and complications in this area upon hospital discharge?

The client and/or family caregiver must be clear on all medication instructions. Families and caregivers need to determine who will set up and manage the medications, as the client may not be the best person to do this for him- or herself. All medications, including pre- and post-hospital meds and over-the-counter meds, should be reconciled. Be sure to update and consult with the primary care physician as soon as possible following a hospital discharge. Due to the complexity of managing the administration of multiple medications at multiple times of day, enlisting the services of a home health nurse may be the best option. Pharmacists can also be an invaluable resource.

What are some of the issues where multiple healthcare providers are involved?

There are often many providers involved after a discharge. Inadequate hand-offs and communication problems between them are major impediments to a smooth transition to home. Home health providers, including nurses and therapists, may get incomplete information from the discharge planner’s referral. Equipment is ordered (or maybe not) and does not arrive on time. Home care aides are often not provided with basic information prior to working with a new client. There’s the potential for no one to follow up on hospital lab results after discharge if the discharge papers didn’t indicate any were pending. Pharmacies are also known to transcribe orders incorrectly, or not know some medications were discontinued or changed at the hospital, and then they don’t fill them correctly or at all.

Do doctors ever talk to each other about their shared patients?

Hospital doctors, or hospitalists, do not talk to primary care doctors as a general rule. This often comes as a surprise to our older clients who were used to a different system for most of their lives. Doctors may share computer records, but those are sometimes incomplete. Up to 50% of patients do not see their primary MD following a hospital stay, though this is essential to the success of ongoing care and is usually included in the “to do” list in discharge instructions. The hospital discharge planner typically does not make this appointment for the client. Referrals are mostly made to specialists, but if the client does not follow up to make an appointment, the specialist may never see the client.

What steps does a care manager take to ensure a smooth transition to home when a client is leaving the hospital?

This is often the time when we first get involved with a new client because the family or involved professional realizes they need an advocate. The Aging Life Care Manager conducts a full assessment that starts with a review of the discharge instructions. Particular attention is paid to any signs that require medical attention, medication changes, any restrictions on physical activity and diet, and any treatments that are needed. The care manager also follows up with the primary care physician and specialty providers while making sure the client and family have a complete understanding of all of the above and consults with them regarding possible needs for home healthcare assistance.

The care manager also discusses with the client and family meal preparation, physical and social activities, transportation needs, financial resources, and client preferences, because a care plan that does not align with the client’s preferences cannot be effective.

The care manager then develops a customized care plan based on this thorough and holistic assessment of the client. The plan addresses both immediate needs and long-term care goals, and it clearly identifies who is responsible for each service. The care manager communicates the completed plan with the client, family, caregivers, and other professionals who may be involved in the client’s care. The care manager then supervises the plan’s implementation.

 

Terry Ehlke recently presented on the topic of hospital discharge planning best practices at the San Diego Regional Home Care Council Spring Symposium in May 2019. Terry was recently promoted to the position of RN Clinical Services Manager at Windward Life Care and is available for assessments and consultation.

San Diego, CA – May 15, 2019 – This month Windward Life Care® reached a milestone, celebrating 15 years of business. Since 2004, Windward Life Care has grown to be one of San Diego County’s premier aging services firms, evolving alongside the rapidly transforming elder care landscape. Starting out with a handful of employees, Windward now employs over 150 office and caregiving staff, following its 2017 acquisition of Lifeline Care, and has served over 2,000 older and disabled adults.

The story of the company began 37 years ago in 1982 when Windward Life Care founder, Norman Hannay, MPS, CMC, first learned about the “integrated model of care” while working with geriatric care management expert B.J. Curry Spitler. In the integrated model, geriatric care managers directly supervise in-home caregivers to create optimal client outcomes. Hannay sought to expand the integrated model of care throughout the county and formed his own company in May 2004, first known as Elder Care Guides. To reflect changes within the geriatric care management profession, the name was changed to Windward Life Care in 2016. Today, Hannay continues to serve as president of the company, which employs a team of social workers, registered nurses, certified care managers, and professional caregivers who work together to care for older and disabled adults throughout the county.

“Norman and I are proud to work with so many people who are as passionate as we are about caring for older and disabled people. I enjoy my daily interactions with our dedicated team of Aging Life Care Managers® and home care aides, who continually strive to be the most compassionate and effective advocates they can be for our clients,” stated Susan Valoff, LCSW, C-ASWCM, current vice president and part owner, with over 20 years of geriatric care expertise. “It brings me great pride to celebrate 15 years in business with our devoted employees, valued clients, and trusted business partners.”

The home care and health care landscapes have transformed since 2004, particularly with the advent of California’s Home Care Organization licensure in 2016. New technologies have become a big factor in how in-home care providers coordinate their efforts and communicate with families. Geriatric care managers are now known as Aging Life Care Professionals®. But, for the most part, the challenges of aging remain the same: families are still spread out over long distances; dementia still poses tremendous challenges to those who live with the symptoms as well as those caring for them, and clients and families continue to need help navigating the complex health care and long-term care systems.

More and more U.S. families are learning the benefits of working with an Aging Life Care Professional who can help long-distance family caregivers have peace of mind and assist older or disabled adults with practical support in the location where they want to live. As members of the Aging Life Care Association, Windward Life Care’s care managers specialize in dementia care, complex family situations, mental health issues, and helping clients age well with a sense of purpose and quality of life.

“Fostering the growth of Windward Life Care has enabled us to serve many more clients and families throughout the county, allowing many people to reach their goal of aging in place in their own homes,” said Hannay. “We remain dedicated to helping our clients age well, honoring their individual goals, and supporting loved ones and involved professionals in making decisions that enhance the client’s quality of life.”

Windward Life Care continues to evolve as a local leader in elder care. The company plans to open a licensed home health agency to serve more medically complex clients and is embracing new technologies that elevate the quality of personalized care services.

Contact Info:

Julie Moore, Director of Business Development

[email protected]

619-450-4300

2045 1st Avenue, San Diego CA 92101

 

About Windward Life Care

Windward Life Care is San Diego County’s premier aging services firm providing Aging Life Care™ Management and expert in-home care. Windward’s clinical staff are members of the Aging Life Care Association® and are experts in the eight Aging Life Care knowledge areas: health & disability; financial; housing; family; local resources; advocacy; legal; and crisis intervention. Windward’s discerning recruitment and rigorous training sets it apart from other home care providers. Each individual client has a personalized plan for aging well. The interdisciplinary professional team at Windward is comprised of leaders in the Aging Life Care Association, including registered nurses and master’s level social workers. Their areas of expertise include dementia care, complex family situations, mental health issues, and helping clients age well with a sense of purpose and quality of life. The company’s office is located at 2045 1st Avenue San Diego, CA 92101. Connect with the company on social: facebook.com/WindwardLifeCare; twitter.com/WindwardLC; or on LinkedIn/Windward Life Care.

AGING LIFE CARE™ is a trademark of the Aging Life Care Association®. Only ALCA Members are authorized to use this term to identify their services. AGING LIFE CARE PROFESSIONAL® is a trademark of the Aging Life Care Association. It is an indication of membership in ALCA, and only ALCA Members are authorized to use this term.

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With all the recent news headlines about measles outbreaks and vaccinations, it’s a good reminder for people of all ages to evaluate their immunization schedule. Are you up-to-date on the immunizations required to strengthen your immune system against avoidable diseases?

Often, older adults assume that they don’t need to worry about this topic because of the vaccines that were given in childhood. The truth is that the CDC recommends a few key vaccines for seniors, helping you maintain optimal health in the later years of your life.

Recommended Adult Vaccines

The first step is to evaluate your immunization history with the recommended CDC adult immunization schedule. Your doctor can help you identify the vaccines that should be administered. Health professionals have found that protection from childhood vaccines can wear off with time.

These are some of the guidelines that should be considered to prevent the contraction and spread of serious diseases:

  • Seasonal Flu: The flu strain changes each year, which means that all adults should receive a seasonal flu vaccine. This immunization is most important for older adults, people with chronic health conditions, and pregnant women.
  • Measles: Outbreaks have been reported across the country, making it more important than ever to stay current with your measles vaccination. The CDC recommends that people born between 1957 – 1967 should be revaccinated now.
  • Tdap: If you did not receive a Tdap as an adolescent, then this vaccine is suggested to avoid the risk of whooping cough. Also, a Td booster is recommended every 10 years.
  • Shingles: Older adults have a higher risk of shingles contraction, which is why it is a good idea to have a shingles vaccine.
  • Pneumonia: This vaccine is recommended for adults 65 years or older, as well as children younger than 2 years old. People between these ages with specific medical conditions might also benefit from the pneumonia vaccine.

While illness and disease are a part of life, there are things that you can do to protect your health and avoid serious health concerns. Staying current with your vaccinations can be an important step in your overall health plan. Do you need assistance in designing a personalized healthcare plan or finding the right health care providers in the area? Windward Life Care is here to help. Call to learn about the available services.