After the Hospital, Then What? A Geriatric Care Manager Can Help!

One problem with aging in general is that most of us are not educated to its problems until we need assistance and by then the issues can be great but where does one find answers. When an older adult has a problem be it physical or emotional the results can be devastating if not dealt with quickly. In general, an older adult typically does not have the physical/emotional reserves to fight off illness and recover to the level they were before the incident. When an older adult goes to the hospital to receive care their in-patient stay is becoming shorter in duration due in large part to insurance regulations attempting to control costs. When discharge time comes either the person returns home or to a skilled rehabilitation center for further physical and occupational therapy combined with nursing oversight and assistance.

The fact remains that once the acute phase of an older adult’s illness/injury passes the demands of daily life continues and for most people, the older adult will prefer to return home. Discharge planners in both hospitals as well as skilled rehabilitation facilities do their best to make appropriate arrangements and referrals for care and services once the patient is discharged but problems can arise once a person is returned to their home. This is where a Geriatric Care Manager may be brought into the case in order to arrange and supervise supportive services. Many family members not to mention concerned friends have daily commitments which make the direct arrangement and supervision of supportive services for the older adult very difficult to accomplish on an on-going basis.

A Geriatric Care Manager is able to evaluate the older adults physical and mental status, what they are able to do by themselves and what outside help they need; family and friend support network and how that may be coordinated to keep the client living independent. A Care Manager also has the knowledge and experience in navigating the health care system and the knowledge of reliable community resources which may be utilized to maximize the client’s safety and comfort in their place of residence. The Care Manager is able to join the needed resources together and monitor the services on an on-going basis thereby allowing family and friends to maintain their daily commitments. The Care Manager will operate from an established Plan of Care which was developed when the Care Manager initially become involved with the client. The Care Manager will refer to this document during their involvement with the client and modify it as necessary in order that it reflects the actual care needs of the client.

In utilizing the skills and experience of a Geriatric Care Manager, the client will be seen on a scheduled basis with the option of additional visits as the needs arise, the family and friends of the older adult will be able to be supportive without trying to identify community resources and then coordinate their provision along with on-going supervision of service delivery and the end result will be a healthier older adult living in an environment of their choosing in which they feel most comfortable.