Services Offered

Comprehensive Evaluation

The Evaluation is the most important first step towards identifying immediate problems and documenting the current status of the client. This extensive report addresses not only the current concerns, but also areas of weakness and vulnerability which could represent ongoing challenges as conditions change. It will become the foundation for managing all aspects of the aging client’s life and living situation.

The Comprehensive Evaluation will:

investigate all aspects of the client’s current living conditions and family support which may include interviewing family members, friends, neighbors and caregivers;

tour the interior and exterior of the residence to point out safety hazards;

review legal documents, particularly the Medical and Durable Powers of Attorney for accuracy and timeliness and review the role of the trusted agent assigned to advocate when necessary;

review chronic medical problems and medications;

discuss quality of life aspects including socialization, activities and interests;  

evaluate activities of daily living and instrumental activities to determine physical and cognitive condition;

make general observations of gait and balance to evaluate for fall risk and inspect mobility devices for function and appropriateness.

The Comprehensive Evaluation is the basis for developing a Plan of Care.  This Plan of Care will become the working tool for all members of the Circle of Care which will include the Geriatric Care Manager.

Ongoing Geriatric Care Management

Coordinate and facilitate recommendations outlined in the Plan of Care as required and agreed upon by the client or legal advocate. Immediate problems are addressed promptly and a longer-term care plan is discussed. Regular communication becomes a critical part of the management process since the condition of the client is always subject to change.

Ongoing Care Management may include:

help with screening, arranging for and monitoring in-home caregivers or help providing respite care for a family caregiver;

making referrals to financial, legal or medical professionals;

identifying helpful services or necessary equipment;          

Help with medication management;

Maintain current medication list among multiple providers;

encourage and promote education related to chronic illness disease progression during aging;

accompanying aging client to medical appointments as advocate and substitute for absentee family member;   

helping the client understand complex topics regarding conditions generally or specially related to the aging process;

act as liaison between family, friends, neighbors and caregivers especially when family is not local;

mediate between family members when there are care management disagreements;

In all cases, by maintaining a close relationship with the client and all members of the Circle of Care, changes in condition can be recognized early, adjustments to the Care Plan made and modifications can be implemented promptly.  Ongoing geriatric care management endeavors to enhance the aging client’s well-being and quality of life through loving kindness, education and advocacy.

Consultation

A one-time consult may be indicated if there is adequate care management by the family but one particular issue presents a challenge that requires investigation, evaluation, coordination and facilitation. The scope of the consult is determined in advance and additional hours dedicated to facilitation of recommendations will become ongoing care management.

Preparing Simple Estate Documents

Geriatric Care Managers are not attorneys and do not offer legal advice. However, simple forms can be prepared, reviewed with all parties, and signing can be facilitated by the care manager in the comfort of the client’s home.

A Living Will and Medical Power of Attorney go hand in hand and are many times included in one document.  The Living Will outlines how the principal would like to be treated if a medical emergency forces incapacity for making medical decisions, generally in a hospital setting.  The Medical Power of Attorney names the person appointed to make those decisions.

A Durable Power of Attorney is a document that is used to appoint a trusted agent to handle more personal affairs of the estate when the principal is no longer able to do so.  This could be the result of a sudden change in condition such as an accident, or a more gradual decline in cognitive health that would prohibit the principal from acting on his/her own behalf.

Wills and Trusts are beyond the scope of the Geriatric Care Manager but referrals to estate attorneys can be shared as required

Placement Services

As conditions change it may be necessary for the aging client to move into a residence that can provide additional assistance. There are a variety of options to consider. The Geriatric Care Manager can help the family understand the range of options and help decide what is best for the client.

Placement services may include:

help with relocation details such as coordinating with transitional specialists to help with downsizing, packing and setting up the new residence;

arranging tours of various facilities or communities;

facilitating the extensive paperwork required prior to moving into assisted living communities;

arranging for medication compliance and transfer to new facility;

referrals to real estate agents, stagers and other professionals when it comes time to sell the client’s home;

The primary goal of the Geriatric Care Manager is to advocate for the client when considering relocation and help the client remain independent for as long as possible, if this is the client’s wish.  But as physical or cognitive conditions change, the Geriatric Care Manager may discuss altering the Plan of Care and recommend that the family consider placement outside the home.

End of Life Counseling

Death is a natural part of life and when irreversible physical or cognitive changes occur and prolonging life unnecessarily becomes detrimental to quality of life, it becomes the responsibility of the loved one’s trusted agent to honor the wishes outlined in the Advance Directive which may include considering palliative or hospice care.

The Geriatric Care Manager can:

Counsel client and family members as to their responsibilities in order to honor the wishes of the client, outlined in the Advance Directive, support the appointed agent, and help facilitate changes to the Plan of Care;

Assess the need for, and coordinate higher level caregiving and other services in the home, if advisable;

Educate the family as to the difference between palliative care and hospice services and help to dispel myths regarding end-of-life care;

Relieve stress by offering guidance as to how to respond to delusions or other cognitive changes brought on by the effects of terminal disease;

Accompany client and family members, if available, to medical provider appointments to discuss options and obtain necessary referrals;

Provide mediation or recommend counseling services for family members who may not agree on changes to the Plan of Care.