| Geriatric Care Managers Lead Highly Skilled Teams |  |
| Geriatric Care Managers Lead Highly Skilled Teams | |
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Coping with Multiple Health Concerns |
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by Rona S. Bartelstone, LCSW, BCD, CMC, C-ASWCMA recent New York Times article (3/31/09) reported on the complications of managing the care of older clients with multiple chronic health conditions. The article states that two-thirds of persons over age 65, and almost three-quarters over 80, have multiple co-morbidities. Despite these numbers, management of this population has not been routinely studied, particularly with regard to helping these individuals manage their medication, dietary, functional, and emotional needs. SeniorBridge is most familiar with this social phenomenon. Our clients are primarily people in their 80’s with an average of four identified health problems and whose families struggle to do the "best" to assure care, safety and quality of life. Most of our clients also have multiple functional challenges. Although the article says this population has not been studied broadly in the medical community, these are the individuals who often show up in community social service agencies with numerous risks because of their confusing health conditions. These are the people who benefit the most from the intervention of professional care managers. Most people live outside the daily routines of the traditional, acute care health system. This means they have to manage their chronic health issues, functional and cognitive changes without the supervision of health providers. This can be complicated and confusing. Unfortunately, lack of oversight, care coordination and consistent follow-up often results in poor health outcomes and other preventable problems, such as falls. Nursing and Social Work Care Managers working in an integrated team with the physician, the family, and the in-home care giver can assure that complex care is properly coordinated, organized, and supervised. Assuring appropriate care in the home setting prevents unnecessary re-admissions to hospitals and frequent use of emergency room care. These are expensive, both finically and with respect to the toll they take on the patient and family caregivers. In fact, a primary cause of premature nursing home admissions is caregiver burnout. Care in the home, alternatively, supports both the family and the caregiver. It is important for family caregivers and patients to understand and have realistic expectations about the care that they need. This helps them to be better consumers of healthcare and to be more compliant with medication, dietary, and physical care regimens. The Social Work/Nurse care management team empowers families to manage their care in a more consistent way when they move from primary care, to hospital, to rehab and back to the home care setting. Managing information and education across settings prevents people from falling through the cracks in the fragmented health and social service delivery system. Everyone needs an advocate when it comes to complex chronic care! The SeniorBridge model of providing health support services along with an attention to the social and emotional needs of the patient and family is one step in the redesign of our healthcare system. |
About SeniorBridge
Why put the care of your loved ones with SeniorBridge? Our company’s unique approach addresses the total well-being of clients and their families through a comprehensive program that includes assessment, planning, service coordination, advocacy, and direct care by an interdisciplinary team led by a geriatric care manager. Read More About Us |
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