Navigating Hospital Discharges with an Aging Life Care Manager

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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.

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Technology for Living Independently and With Dignity at Home

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The great majority of older adults have a strong desire to live in their own homes and communities; but many adaptations need to be made in our homes to accommodate this. Technology is one piece that empowers older adults to live in their homes with dignity.

Technology has been challenging for many mature adults to comprehend and use; first it was computers, then came smartphones, both of which required investments to own and skills to use. With the advent of voice enabled technologies and AI software (artificial intelligence), access and interaction with technology has never been friendlier. Voice assistants like the Amazon Echo or Google Home which start to retail at $49, users can in their own native language interact with a whole slew of services and hardware products which earlier could only be accessed using a computer or a smartphone.

Increasingly, the ground zero of senior well-being is now shifting to their lifestyles at home; sensors are becoming more context driven, data captured and analyzed by non-intrusive sensors and wearable devices help us predict potential health situations and challenges ahead of time moving us to the realm of predictive healthcare.

Here are the many ways that technology enables us to interact with our homes to enhance our well-being and lifestyle:

Comfort and Convenience
Control lighting switches, thermostat temperature and your entertainment system with voice commands.

Security & Safety
Routine activities and social support are especially suited for elders suffering cognitive decline. These systems detect changes in patients location or environment and provide verbal assistance as needed, or if needed, notify caregivers.

Isolation and Loneliness
Using voice assistants like Amazon Echo and Google Home to communicate with family friends and caregivers, staying informed, ordering supplies, booking transportation, conducting basic banking, restaurant delivery services.

Monitoring & Predictive Health
Smart sensors for monitoring activity and behavior; which serve as advance warning systems for potential health challenges.
Video devices for security.
Video cameras with AI for facial recognition, automated door locks for locking, video doorbells managing visitors without getting to the front door.

Wearables for Health Analytics
Health monitoring systems to monitor blood pressure, pulse, and movement of the patient as well as environmental data, such as ambient temperature.

Fall Protection and Management
Sensors that can detect a fall both inside and outside the home and notify emergency services and caregivers in real time.

Lighting for Well-being
LED circadian rhythm lighting for normal sleep patterns, and creating a positive environment.

Going Forward
The next phase of technology for seniors is being designed using Ambient intelligence; which combines AI (artificial intelligence) and IoT (internet connected devices), will provide real-time monitoring of an environment and event-driven response to changes in that environment. Sensors designed to detect changes in sound, motion, physiological signals, as well as more generalized image processing are core components of an ambient intelligent environment.

About Smaart House

Smaart House is a San Diego based technology provider for senior care, our purpose is to empower mature adults to live independently and with dignity in their home environment and communities. We work with individual homeowners, senior care communities and assisted living facilities to integrate and adapt technology in their environments. Please visit us at www.smaart.house for more information.

The author Bijou Lulla is the Founder and CEO of Smaart House, he can be reached at [email protected].

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How Can Occupational Therapy Help Me?

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The month of April is known as “Occupational Therapy Month,” designated as an opportunity to shine a light on the benefits that are available from these services. Occupational therapy can be helpful for people of all ages, particularly aging adults.

What is Occupational Therapy?

Age or disabilities can limit a person’s ability to complete everyday tasks. Occupational therapy practitioners enable patients by helping them function despite a disability, illness, or injury. Sometimes these services are used for children with disabilities or people recovering from accidents. Other times, practitioners help older adults who are working through cognitive and physical changes.

Occupational therapy services start with an evaluation to determine the person’s goals. A physician order is required for health insurance to cover the assessment and ongoing OT services. After the assessment, a custom treatment plan is put together to assist the person in reaching those goals. Ongoing therapy is adjusted based on outcome evaluation, with the practitioner making changes as needed. Finally, cooperation with family members, caregivers, and other professionals is necessary to ensure the long-term support to help the person as needed.

Maintain Independence in Retirement

If you are planning to remain in your home in the later years of life, then occupational therapy might be a good solution. The normal aging process can make it challenging to keep up with personal care, housekeeping, and yard work. An occupational therapist can support your goals by designing a plan that increases independence while maintaining safety at home.

There are times when family members might need to encourage support of aging parents. If you can see that your parents are finding it difficult to keep up with tasks in the home, then it is time to start the conversation about options that are available. Occupational therapy services are always customized to the person’s environment, skills, needs, wants, and budget.

Many times, families don’t know where to turn when these life changes are occurring. Instead of navigating the challenges without assistance, consider the support of our team. At Windward Life Care, we are experienced in helping individuals and families find the care and services that are needed. Our team is here to help you find an occupational therapist or other supportive professionals based on your situation. Call to learn more about the ways that we can help.

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Avoiding Common Scams Aimed at Seniors

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The County of San Diego handles an estimated 9,000 cases of elder abuse annually. If that many cases are reported, how many elder abuse situations are going unreported? Abuse can happen in many forms, including physical, financial, sexual, emotional, and more. Victims might be living in silence, with family and friends unaware that problems are occurring.

The Elderly are Targets for Financial Abuse

Financial abuse is one of the most common forms of elder abuse. Predators know that older adults have access to retirement funds and ongoing paychecks. Unfortunately, scammers are looking for ways to tap into these resources and take advantage of people who might unknowingly hand over financial information.

Older adults are vulnerable because they are often too trusting of other people. A phone call, mailer, or a conversation on the doorstep with a stranger might seem like a harmless situation. But, the stranger can build trust with the person and then take advantage of them financially.

To make matters worse, family members might also be the perpetrators. For example, children or grandchildren might steal money or valuables like jewelry, rationalizing that they would have received these assets as an inheritance eventually. When people are in desperate circumstances, the risk increases that they will take advantage of another person.

Common Types of Senior Scams

To protect yourself, your loved ones, and/or clients from being “easy targets,” you can take a few easy steps.  Jewelry theft is extremely common, in both home and facility settings, so take the time to photograph valuables and lock them up.  Buy a shredder and ensure that any paperwork with your Social Security number, financial information, or other identifying information is shredded to protect against identify theft. If you need caregiver help, work with a licensed, reputable home care agency that screens and oversees its staff. And, be aware of the common financial scams that are going around right now:

  • Sweepstakes mail, causing the victim to hand over financial information to receive their prize
  • Investment schemes, draining a victim’s retirement account
  • Sales-Pitch luncheons, free lunch to pull people into a high-pressure sales environment
  • Fake IRS calls, misleading people to think that they are in trouble with the IRS
  • Grandparent scams, phone calls that trick older adults to provide payment because they think that a grandchild is in trouble

If you want to keep your family protected, then download this elder abuse prevention toolkit provided by San Diego County. Also, talk to our team at Windward Life Care to find other professional services that can help.

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Client Story: Maintaining Independence in Times of Crisis

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As we age, it can become harder to navigate unforeseen, life-altering events on our own. At Windward Life Care®, our Aging Life Care™ Managers are trained to help clients maintain their independence despite adversities. The following story demonstrates one of the many ways our Care Managers create personalized plans of care that emphasize the client’s goals and maximize freedom and quality of life — even in times of crisis. 

Aging Life Care Manager Story: Camille and Heather

Camille is a 63-year-old-woman with special needs who had been living in a partially flooded home for over a year without alerting anyone to her situation. The flood had destroyed the interior of her house and nearly all of her personal belongings. She needed extensive assistance moving into a safe space and getting back on her feet after this disaster had left her vulnerable and without direction.

After learning of the state in which Camille had been living, her trustee contacted Windward for help. Heather Arsenault, an Associate Care Manager at Windward, instantly relocated Camille into an extended-stay hotel with kitchen amenities and laundry service. Over the next several months, Heather worked diligently with Camille to put together a long-term plan.

Heather found a new apartment that would meet Camille’s needs while granting her the autonomy she longed for. “I was given a limited budget to furnish the one-bedroom apartment including the bedroom and living room furniture, kitchen appliances, and television,” said Heather. Heather shaped the apartment into a comfortable home.

Heather coordinated the lease, gas/electric and cable and transferred Camille’s mail to the new apartment. After it was discovered that Camille did not have health insurance, Heather researched her eligibility for government benefits and soon Camille was granted Medi-Cal coverage that allowed for personalized at-home assistance.

Heather’s compassion and dedication gave Camille the ability to maintain her sense of independence in a safe and supportive living environment. “Now she is living on her own in the apartment with a caregiver visiting twice a month and assisting her with laundry, grocery shopping, and errands,” said Heather. “Camille is so excited to be on her own again and is thankful for all that we did for her.”
We are dedicated to supporting our clients and willing to go above and beyond to bring together the right resources. The reward is bringing peace of mind to clients like Camille; this inspires each of us to do even more every day.

Windward Life Care’s interdisciplinary team of Aging Life Care™ Managers has certification and professional training in a number of areas related to healthy aging, including nursing, geriatric care management, and social work. If you would like us to create a personalized plan for yourself or someone you care about, please visit: https://windwardlifecare.com/what-we-do/aging-life-care-management/

*Due to respect of our clients’ privacy, some names have been altered.  

 

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Making Your Move a Smooth One

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Have you reached a point in your life where you are ready to “right-size” to a smaller home, or move into an independent or assisted living community?  While you may be excited about simplifying your life and getting rid of excess “stuff,” there is no doubt that a move later in life can have its complexities.  If you are preparing to move, then we recommend you have an experienced team in place to assist with these changes.

Getting Past the Overwhelm of Decluttering

One of the biggest hurdles with downsizing is deciding what to take with you. It can feel overwhelming to sort through a lifetime of items in your home. Family pictures, birthday presents, holiday décor and childhood toys can often fill the storage spaces. How do you sort through these items in a way that allows you to fit into your new home comfortably, but preserves your family memories?

Senior Move Managers are professionals who specialize in helping older adults with the task of downsizing and moving to a new residence. They know the nuances of moving later in life, and they can offer specialized services to optimize your experience. For example, they can obtain the floor plans of your new residence, help you measure your existing furniture, then determine which pieces to bring with you. Senior Move Managers can also coordinate packing, moving, and set up your belongings in your new home. For those things you decide not to bring along, a Senior Move Manager can help coordinate an estate sale or the donation of less valuable items. Look at the National Association of Senior Move Managers for more information.

Senior Real Estate Specialists

For many older adults, their home is their most valuable asset. How do you make sure you are getting the most value when you are selling your home and choosing your next residence? Senior Real Estate Specialists® are Realtors® with specialized expertise in helping adults 50+ with relocation, financing and selling their home.  With their involvement, you can have the confidence that your transaction will be handled with patience and professionalism, and that they will link you with other professional resources appropriate for your needs. Are you contemplating a move or other life change? Then you need to talk to our team at Windward Life Care. We offer a variety of services to support lifestyle and health as people age.

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